cqc horton report

This report describes our judgement of the quality of care at this hospital. It is based on a combination of what we foundwhen we inspected, information from our 'Intelligent Monitoring' system, and information given to us from patients, thepublic and other organisations.

Ratings

Overall rating for this hospital Good –––

Accident and emergency Good –––

Medical care Good –––

Surgery Good –––

Intensive/critical care Good –––

Maternity and family planning Good –––

Services for children & young people Good –––

End of life care Good –––

Outpatients Good –––

Oxford University Hospitals NHS Trust

HortHortonon GenerGeneralal HospitHospitalalQuality Report

Oxford RoadBanburyOxfordshireOX16 9ALTel: 01295 275500Website: www.ouh.nhs.uk

Date of inspection visit: 25 February and 2 March2014

Date of publication: May 2014

1 Horton General Hospital Quality Report May 2014

Contents

PageSummary of this inspectionOverall summary 3

The five questions we ask about hospitals and what we found 5

What we found about each of the main services in the hospital 7

What people who use the hospital say 12

Areas for improvement 12

Good practice 12

Detailed findings from this inspectionOur inspection team 14

Background to Horton General Hospital 14

Why we carried out this inspection 15

How we carried out this inspection 15

Findings by main service 16

Summary of findings


Overall summary

Horton General Hospital is an acute general hospital inBanbury in North Oxfordshire. The hospital has a longhistory from first opening with two wards in 1872. Itbecame part of the Oxford University Hospital NHS Trustin 1998. It provides a range of services including anemergency department (A&E), general surgery, acutegeneral medicine, trauma and orthopaedics, maternityservices, a children’s ward and special care baby unit(SCBU), critical care, coronary care, a cancer resourcecentre, and dialysis. The hospital serves a catchmentpopulation of around 150,000 people in and aroundNorth Oxfordshire and neighbouring communities insouth Northamptonshire and south east Warwickshire.There were 248 inpatient beds and the hospital sawaround 120,000 patients as inpatients each year. Thehospital arranged in the region of 90,000 outpatientappointments each year and saw 36,000 people eachyear in the emergency department.

To carry out this review of acute services we spoke topatients and those who cared or spoke for them. Patientsand carers were able to talk with us or write to us before,during and after our visit. We listened to all these peopleand read what they said. We analysed information weheld about the hospital and information fromstakeholders and commissioners of services. Peoplecame to our two listening events in Banbury and Oxfordto share their experiences. To complete the review wevisited the hospital over two days, with specialists andexperts. We spoke to more patients, carers, and staff fromall areas of the hospital on our visits.

The services provided by Horton General Hospital weredelivered to a good standard. Patient care in all thedepartments and services we visited was delivered safely,by caring staff who were well led. The hospital wasdelivering effective care although needed to review howpatients in critical care were supported safely byconsultants with the relevant training. Staff told us theywere well supported by one another and their managers.The overriding comment from the nurses we met wasthem telling us the reason they came into work each daywas the support they gave one another. Departments,wards and services were well led at a local level, but therewas some concern around overall leadership of thehospital as staff told us they felt there was no one with

overall responsibility. This was because the trust workedin directorates, and different senior staff were responsiblefor different parts or divisions of the hospital. Staff told uson occasion an issue in one department could impactanother and it was sometimes hard to find a resolutionwithout a general manager.

A number of people from the local community we met atour listening event in Banbury said they were notconsulted by the trust about changes made to theprovision of services. People, patients and staff wereconcerned specifically about the removal of emergencysurgery from the hospital. The main concern of staff wasfeeling their voice was not heard by the trust. The trusttold us about the communication exercise undertaken toinform all internal and external stakeholders about thedecision and rationale to remove emergency abdominalsurgery from the hospital. This involved meetings withthe Community Partnership Network.

StaffingThe hospital was and had been actively recruiting staff,particularly to nursing posts. Some staff were concernedabout the future of the hospital and rumours ordiscussions about its future. They said they knew this haddeterred some staff from actively looking to work at thehospital and meant there was a high level of locum staffat times. Most staff felt the hospital was, however,well-staffed most of the time. Nurses and doctors saidthey felt they had enough time to spend with patients,although they said there could always be more. Nursemanagers said they usually had time for their managerialduties, but would step in to direct care provision whenthe department or ward was short-staffed. Some staffsaid training was usually the first thing postponed if theirarea was short-staffed, but otherwise the trainingcompletion rate was high.

Cleanliness and infection control.The hospital was clean on both our announced andunannounced visit. Staff followed cleaning schedules,paying attention to hard-to-reach areas, and most areaswere organised to make cleaning as efficient as possible.We observed good infection control practices amongstaff. Staff were wearing appropriate personal protective

Summary of findings


equipment when delivering care to patients. There was arelatively good provision of hand gels across the site andwe saw staff using them and asking patients to do the

same. The number of MSRA bacteraemia infections andClostridium difficile infections attributable to the hospitalwere within the acceptable range for a hospital of thissize.

Summary of findings


The five questions we ask about hospitals and what we found

We always ask the following five questions of services.

Are services safe?Services at the hospital were safe. Staff were trained and responsive to anysigns of abuse and avoidable harm. They were open and transparent whenthings went wrong, investigated them and made changes to avoidrecurrences. The hospital was clean and infection control protocols werefollowed. Medicines were managed safely. Staffing levels were acceptable anddepartments responded well to busy times.

Emergency services were safe, although some aspects of the provision forchildren did not follow the guidance for paediatric emergency care. Thisincluded challenges from the environment, which had been recognised bystaff. The majority of training was delivered on time, although there was a lackof specific training for staff in A&E for supporting people with dementia.Maternity and children’s services were safe, and staff followed best practiceguidance. End of life care was delivered well across the hospital and linkingwith community services to follow best practice. Medical and surgical care wasdelivered to ensure patients were safe. Staff said they were encouraged toreport anything they felt was not safe and it was addressed.

The critical care service provided excellent care with good outcomes. But theservice was not meeting guidance in relation to medical cover. There wereexperienced anaesthetists and consultants attached to the unit, but not allhad critical care training. There was no critical care Outreach service in thehospital, although we were told this was being discussed and the servicecould be reintroduced.

Patients with cognitive impairments were supported to make decisions, butwhen they were not able to, the requirements of the Mental Capacity Act 2005and multidisciplinary decisions acting in people’s best interests werefollowed. Otherwise, patients and their partners were involved in decisionsand made their own choices.

Good –––

Are services effective?Outcomes for patients were good and the hospital performed well whenmeasured against similar organisations. National guidelines and best practicewere applied and monitored, and outcomes for patients were good overall.Pain management was done well, and patients were supported with goodhydration and nutrition. Staff worked in multidisciplinary teams to co-ordinatecare around a patient. End of life care was integrated across the hospital andwith community services. Staff were supported to be innovative and werecontinually looking to improve services. Most mandatory training andappraisals were on track to be completed annually. New mothers were wellsupported and children and young people’s services were effective.

Good –––

Summary of findings


Are services caring?During our inspection, we observed almost all staff were caring and patientsconfirmed this, saying that staff were considerate, and treated them withkindness and respect. Patients and carers coming to the maternity andchildren’s services said that staff were welcoming, caring, and kind. A&E staff,outpatient staff and ward-based staff were praised for their kindness. Staff inthe critical care team provided good care and emotional support. End of lifecare, which was provided across the hospital where needed, was caring,professional and supportive to patients’ choices.

Support for patients with mental health needs, particularly in the A&Edepartment, was not always adequately covered. This had improved recently,but out-of-hours or weekend provision was limited.

Good –––

Are services responsive to people’s needs?The hospital supported vulnerable patients well, to ensure care was deliveredin their best interests. Discharge arrangements were usually managed well.Bed occupancy at the hospital was sometimes at a level that had an impacton the quality of care, and caused the A&E department to miss waiting-timetargets for patients. The critical care unit occasionally had not met dischargetargets, as there were sometimes no beds available into which to movepatients who were recovering. Patients were sometimes delayed by theirdischarge into community care not being arranged in good time by otherproviders. There had been changes made to provide patients ready to gohome with support in the day-case lounge to expedite discharge and releasebeds to the ward.

The trust said it had consulted with local people about changes at thehospital. However, people we met particularly at our Listening Event inBanbury said they were not consulted, and specifically not about thecancellation of the provision of emergency surgery at the hospital. The trusttold us about the communication exercise undertaken to inform all internaland external stakeholders about the decision and rationale to removeemergency abdominal surgery from the hospital. This involved meetings withthe Community Partnership Network.

Good –––

Are services well-led?Staff told us they felt the hospital was well-led at a local departmental level.Staff were supported by their peers and managers to deliver good care and tosupport one another. Staff said they felt proud to work at the hospital, but didnot feel at all times they were included and consulted in plans and strategiesby the trust. Some staff described this as feeling isolated.

There was a lack of support for some newly qualified midwives and some staffin the maternity ward felt morale was low. Most staff said, however, they hadgood appraisals with their managers each year and could discuss mattersopenly and had no fear of reporting concerns.

Good –––

Summary of findings


What we found about each of the main services in the hospital

Accident and emergencyThe A&E department at The Horton General Hospital provided overall goodsafe care. The department had qualified and experienced staff with stronglocal leadership and direction. Patients told us they felt safe at thedepartment. Systems and processes worked to keep people safe and givethem the most appropriate care and treatment. Staff were caring andcompassionate. Patients said their privacy and dignity was preserved and theyfelt treated as individuals.

Staff were dedicated to their patients and their service. They were committedto making improvements and listening to patients. There were few complaintsmade to the service, but those that were made were addressed and learnedfrom. There was an open culture among staff where any care or treatment oravoidable incidents were discussed and ways to improve were recognised andimplemented. The morale in the department was affected, however, byuncertainty about the future of the hospital. Staff felt this was not helping withlocal recruitment of nursing staff.

Patients we met described the service as “excellent”, said: “I have nocomplaints. They have been absolutely wonderful”, “I feel treated like a personhere and like I really matter to these staff”, and: “I’ve been here a number oftimes and with my kids too, and the care has been first class. Nothing butpraise for these staff. They work really hard and it’s not always easy for them.”

From raw data sent to us by the trust, we saw the department had breachedthe Government’s four-hour waiting time target on occasion. The data did notprovide any detail of the reason for these breaches, but staff confirmed it wasmostly due to their not being an available bed for the patient to be transferredinto. There was no evidence this was due to staff in A&E not treating thepatient in good time to facilitate their discharge. There had also been nospecific increase in patient numbers attending A&E in the recent wintermonths. The busiest months in 2013 were in the summer period.

Good –––

Medical care (including older people’s care)The hospital provided safe care. National tools were used to measure risks topatients and action was taken to address identified risks. Staffing levels wereregularly monitored to ensure wards and departments were adequatelystaffed. Integrated care pathways for inpatients with diabetes were still beingdevised. Actions included a business case to bring diabetes inpatientspecialist nurse numbers in line with the national average as well as early andcomprehensive standardised assessments.

Staff were caring. Patients spoke highly about the care they received and thekindness and helpfulness of the staff. Staff worked effectively andcollaboratively to provide a multidisciplinary service for patients who had

Good –––

Summary of findings


complex needs. Patient views and experiences were sought by the hospital, bythe provision of quality questionnaires, and the responses were fed back tostaff on the wards. The hospital demonstrated openness to engage withpatients and listen to their feedback to improve the services provided.

SurgeryThere was consensus among patients, carers and staff that staff werededicated and provided compassionate, empathetic care. Processes werefollowed to reduce any risks to patients undergoing surgical treatment. Therewere processes to ensure patients who moved to different wards receivedconsistent and safe care and treatment. Staff made use of the language linefacility and interpreters to ensure patients had good understanding of theirtreatment and were able to make informed decisions. Staff had a goodunderstanding of the Mental Capacity Act 2005 which meant patients receivedthe appropriate support to be able to make their own decision, or whererequired decisions involving appropriate people were made in the bestinterest of the patient.

Generally, there was sufficient equipment available to meet the needs ofpatents. However, concerns were expressed about access to MRI imaging.Patients had to go to the John Radcliffe Hospital in Oxford to access MRIimaging; we were told that difficulties in arranging appointments meant therewas a risk that some patients’ treatment would be delayed.

We saw good evidence of team working at ward and departmental level.However, with some of the clinicians, there was a feeling that despite beingpart of Oxford University Hospitals NHS Trust, the views and opinions of staff atHorton General Hospital were not always heard.

Good –––

Intensive/critical carePatients received care which was compassionate, dignified and deliveredgood outcomes. Clinical outcomes for patients were good. Mortality rates werebelow the national average and below the expected level for patients in acritical care unit. The caring and consideration of staff was excellent. Thepatients and relatives we spoke with praised the nursing and medical staffhighly. Vulnerable patients were well supported and staff put the patient at thecentre of their care.

The department was well-led at local and senior level and staff weresupported and proud of their work. There were some issues with patientdischarge not being timely or being delayed, but this was due to pressures onbeds elsewhere in the hospital. On a national level, this problem was notsignificant.

However, the critical care department was not meeting the guidelines inrelation to medical cover. There were skilled and experienced anaesthetistsand consultants attached to the unit, but not all had critical care training. The

Good –––

Summary of findings


lead medical consultant was trained in critical care, but this was not theirsubstantive post and they were not available at all times. There was noevidence this had resulted in patients being put at risk, but the arrangementsdid not meet the national guidelines for medical care in intensive care units.

Maternity and family planningThe maternity unit at the Horton provided safe care which was tailored to theneeds of women receiving pre- and post-natal care.

Women received care from caring, compassionate and skilled staff. Wereceived positive comments from women and their families about the careand support they received. They were involved in decisions about their careand received emotional support as required.

The unit was clean and staff followed the internal procedures for handwashing. Hand gels were available at different points and visitors wereencouraged to use them. Staff had completed training in infection control toensure women and babies were protected from the risk and spread ofinfection.

There were systems in place to record near misses and other events and thestaff were aware of their responsibility to record and report these incidents.There was evidence that learning from incidents occurred and action plandeveloped.

People were safeguarded from the risk of abuse. Staff had received training insafeguarding and were aware of the process to report any such issue. Thisensured patients were not put at risk as appropriate safeguards were in place.

Most practice was in line with national guidelines. There were concerns aboutthe lack of support for newly qualified midwives which may impact on caredelivery. The labour delivery suite had been without a manager and there wasa lack of succession planning.

The service was well-led. There were clinical governance strategies andregular meetings which looked at development of the service. Staff feltsupported within the ward and units; however, they told us they feltdisconnected from the wider organisation.

Good –––

Services for children & young peopleWe visited the children’s ward on a Tuesday and a Wednesday during thedaytime and again on a Sunday afternoon and early evening as anunannounced visit. During these visits we talked with around nine patientsand their relatives accompanying them. We spoke with staff, including nurses,doctors, consultants and support staff. We also received information frompeople who attended our listening events and from people who contacted usto tell us about their experiences. We collected comment cards from adesignated box set up for our visit. Before our inspection we reviewedperformance information from, and about the trust.

Good –––

Summary of findings


There was a multidisciplinary collaborative approach to the care andtreatment of children across children's services in the hospital. Children's careand treatment was planned and well documented in the medical notes andnursing records in the patient's files. Staff across children’s services wereconfident the hospital had a reliable system to alert them to risk andimplement improvements. Staff told us they could express their views in wardmeetings and were “confident” they would be listened to by the organisation.

Children and young people received person centred compassionate care fromstaff in the children’s ward. We saw nursing staff delivered kind andcompassionate care to a young child who was crying as their mother had gonehome. Parents told us nursing staff had been “patient and kind.”

End of life carePatients received effective and sensitive end of life care. Patients told us theyfelt safe with the staff and overall their needs were met. We were toldmedicines were prescribed to control patients’ pain and staff were using thefast-track process for early discharge. Patients said staff respected their rights:in particular privacy and dignity. Patients and their relatives told us wherethere were concerns staff were available for discussions.

Patients at the end of their life were able to make decisions about the medicalprocedures to be followed in the event of cardiopulmonary arrest. If thedecision made was not to attempt to resuscitate the patient, it was recordedand brought to the attention of all medical staff involved in the delivery ofcare.

Patients were treated with compassion and were not expected to wait for painmedication. Doctors prescribed medicines in advance to prevent delays inadministering medicines to patients in pain. Medicines to be taken as requiredwere prescribed to ensure patients were comfortable between otherscheduled medicines.

Patients were cared for by staff with an understanding of end of life care. Therewere nurses on each ward who specialised in specific topics including end oflife care. These staff were able to support other staff who needed guidance oradvice. Doctors completed mandatory training on end of life care during theirteaching.

Good –––

OutpatientsPatients received safe care. Staff were skilled and caring and knew theirresponsibilities to keep patients safe. Risk assessments had been completedand actions identified to improve the service. The clinic was clean and arefurbishment programme had started. Capacity remained a concern becausedemand had increased by 10% over the year prior to our inspection. The trust

Good –––

Summary of findings


was planning to improve capacity at the Horton by providing two additionalclinic rooms in the refurbishment. Audits for the “choose and book” systemhad taken place and the trust was in the process of re-profiling outpatients toimprove the patient experience.

We spoke with ten patients and the majority had no problem getting anappointment and all tests and x-rays had been completed in a timely manner.Eight patients were complimentary about the service and two told us theservice was excellent overall. Two patients had problems getting anappointment in a timely manner.

There was a culture between staff to improve the patient experience and bethe best they could be. Patient views and experience had been sought to helpimprove the service. Staff had endeavoured to answer any verbal concernsraised with them immediately.

The trust were keen to develop directly bookable appointments that relievedpressure on staff and the time it took patients to book individualappointments over the phone. The plan was to improve the time automaticletters were sent for appointments and cancellations.

Summary of findings


What people who use the hospital say

The A&E department did well in the NHS Friends andFamily Test with the majority of results each month muchhigher than the England average in April to December2013. In July 2013, for example, the response rate was25.3% (England average 10.4%). Of the 480 responses, 456people said they would be “extremely likely” or “likely” torecommend the department to their friends and family.Only 6 people said they would be “unlikely” or “extremelyunlikely” to recommend the department. In November2013, the response rate was 21.5% (England average15.2%). Of the 322 responses, 307 people said they would

be “extremely likely” or “likely” to recommend thedepartment to their friends and family. Only two peoplesaid they would be “unlikely” or “extremely unlikely” torecommend the department.

The Patient-Led Assessment of the Care Environment(PLACE) survey from 2013 rated cleanliness of the hospital80.5%; food 85.8%; privacy, dignity and wellbeing 75.9%and facilities 74.3%. Ratings on the NHS Choices website(from between 31 and 38 ratings) rated the hospital with4.5 stars overall, 4.5 stars for cleanliness; 4.5 stars for staffco-operation; 4.5 stars for dignity and respect; 4 stars forinvolvement in decisions; and 4 stars for same-sexaccommodation.

Areas for improvement

Action the hospital SHOULD take to improve

• The hospital should have cover at all times frommedical staff trained in critical care.

• The hospital needs to ensure it has sufficient bedcapacity for A&E to meet Government target waitingtimes.

• Staff, specifically in the A&E department should haveregular training in supporting people with dementia.

• Although all A&E staff were trained in paediatric lifesupport, guidance said the department should havetrained paediatric nurses on duty at all times.

• Clinical notes for patients in the medical wards shouldinclude a records of all agreed care given to patients.

• Patients should have access to specialist medicalservices when they are needed.

• The hospital trust should improve support to localstaff so they feel more included and less isolated.

• The kitchen in the critical care unit should be bettersecured from the clinical area.

• The provision of an outreach service for critically illpatients should be revisited.

• Support for newly-qualified midwives (through theirpreceptorship programme) should be improved alongwith management of the maternity services.

• Decisions made by patients around resuscitationshould be reviewed as required.

Good practice

Our inspection team highlighted the following areas ofgood practice:

• The care and support given to patients and theirrelatives in critical care was excellent.

• The stroke service in A&E followed a clear pathway anddelivered good outcomes to patients.

• Staff worked well between wards to ensure safestaffing levels were maintained.

• There were good outcomes for patients in critical care.Mortality was below national averages.

• Staff were proud of their hospital and the care theyprovided to patients.

• Multidisciplinary team working helped to meet thecomplex needs of patients.

• Auditing and monitoring of care ensuredimprovements in practice.

• Staff spoke highly of their peers and the support theyreceived from their line managers.

Summary of findings


• The services provided by the day hospital hadincreased to enable patients to be discharged to theday hospital while waiting for medication to takehome or transport so that the medical wards couldadmit new patients.

• Staff were encouraged and supported to innovate andwere proactive in making and promoting changes.

• Team leaders and managers focused on the skill mix oftheir staff to ensure services were delivered safely.

• The bereavement suite provided good supportincluding pastoral care.

• Staff spoke highly of the consultant-led children’s wardand the good outcomes for children.

Summary of findings


Our inspection teamOur inspection team was led by:

Chair: Dr Chris Gordon, Director, Foundation TrustSupport Programme at NHS Top Leaders, Department ofHealth & Consultant Physician at Hampshire HospitalsFoundation Trust

Team Leader: Mary Cridge, Head of HospitalInspections, Care Quality Commission

The team of 51 (of which 20 visited Horton GeneralHospital) included CQC inspectors, managers andanalysts, consultants and doctors specialising inemergency medicine, obstetrics and gynaecology,oncology, diabetes care, cardiology and paediatrics. Italso included junior doctors, a matron, nursesspecialising in care for the elderly, end of life care,children’s care, theatre management, cancer andhaematology and two midwives, together with patientand public representatives, and experts by experience.Our team included senior NHS managers, including twomedical directors, a deputy chief executive and a clinicaldirector in surgery and critical care.

Background to HortonGeneral HospitalHorton General Hospital is an acute general hospital inBanbury in North Oxfordshire. It provides a range ofservices including an emergency department (A&E), generalsurgery, acute general medicine, trauma and orthopaedics,maternity services, a children’s ward and special care babyunit (SCBU), critical care, coronary care, a cancer resourcecentre, and dialysis. The hospital serves a catchmentpopulation of around 150,000 people in and around NorthOxfordshire and neighbouring communities in southNorthamptonshire and south-east Warwickshire. Therewere 248 inpatient beds and the hospital saw around120,000 patients as inpatients each year. The hospitalarranged in the region of 90,000 outpatient appointmentseach year and saw 36,000 people each year in theemergency department.

To carry out this review of acute services we spoke topatients and those who cared or spoke for them. Patientsand carers were able to talk with us or write to us before,during and after our visit. We listened to all these peopleand read what they said. We analysed information we heldabout the hospital and information from stakeholders andcommissioners of services. People came to our twolistening events in Banbury and Oxford to share their

HortHortonon GenerGeneralal HospitHospitalalDetailed Findings

Services we looked atAccident and emergency; Medical care (including older people’s care); Surgery; Intensive/critical care;Maternity and family planning; Services for children & young people; End of life care; Outpatients


experiences. To complete the review we visited the hospitalover two days, with specialists and experts. We spoke tomore patients, carers, and staff from all areas of thehospital on our visits.

The hospital is registered to provide assessment or medicaltreatment for persons detained under the Mental HealthAct 1983; diagnostic and screening procedures; familyplanning; maternity and midwifery services; nursing care;personal care; surgical procedures; termination ofpregnancies; and treatment of disease, disorder or injury.

Why we carried out thisinspectionWe inspected this hospital as part of our in-depth hospitalinspection programme. We chose this hospital becausethey represented the variation in hospital care according toour new intelligent monitoring model. This looks at a widerange of data, including patient and staff surveys, hospitalperformance information and the views of the public andlocal partner organisations. Using this model HortonGeneral Hospital was considered to be a medium risk-levelservice and the trust is an aspirant Foundation Trust.

How we carried out thisinspectionTo get to the heart of patients’ experiences of care, wealways ask the following five questions of every service andprovider:

• Is it safe?• Is it effective?• Is it caring?• Is it responsive to people’s needs?• Is it well-led?

The inspection team always inspects the following coreservices at each inspection:

• Accident and emergency• Medical care (including older people’s care)• Surgery• Intensive/critical care• Maternity and family planning• Services for Children & Young People• End of life care• Outpatients.

Before visiting, we reviewed a range of information we holdabout the hospital and asked other organisations to sharewhat they knew about the hospital. We carried out anannounced visit on 25 February 2014. During our visit weheld focus groups with a range of staff in the hospitalincluding nurses below the role of matron, matrons, juniordoctors and consultants. We talked with patients and stafffrom all areas of the hospital including the wards, theatre,outpatient departments, and the A&E department. Weobserved how people were being cared for and talked withcarers and/or family members and reviewed personal careor treatment records of patients. We held listening eventswhere patients and members of the public shared theirviews and experiences of the location. An unannouncedvisit was carried out on the 2 March 2014 when we visitedA&E, the children’s ward and the critical care unit.

Detailed Findings


Safe Good –––

Effective Not sufficient evidence to rate

Caring Good –––

Responsive Good –––

Well-led Good –––

Information about the serviceThe A&E department was open 24 hours a day, seven daysa week to provide an emergency service to the people ofBanbury and the surrounding areas. The department had14 beds and treated people with both minor and majorinjuries and illnesses. About 36,000 patients (27,500 adultsand 8,500 children) were expected to attend thedepartment each year. The department triaged patients asthey were admitted to ensure they were quickly assessedfor the need for any urgent intervention. The departmentused the adjacent Emergency Admission Unit (EAU) forpatients who needed ongoing observation or assessmentbefore they were admitted to hospital, transferred ordischarged. The matron for the Emergency Departmentalso covered this service. Patients transferred to the EAUremained under the care of the doctor or medical teamtreating them in the emergency department until their carewas handed over or they were discharged.

We visited the A&E department on a Tuesday during thedaytime and again on a Sunday afternoon and earlyevening as an unannounced visit. During these visits wetalked with around 20 patients and their relatives or friendsaccompanying them. We spoke with staff, including nurses,doctors, consultants, support staff and ambulancepersonnel. We also received information from our listeningevents and from people who contacted us to tell us abouttheir experiences. We collected comment cards from adesignated box set up for our visit. Before our inspectionwe reviewed performance information from, and about thetrust.

Summary of findingsThe A&E department at The Horton General Hospitalprovided overall good safe care. The department hadqualified and experienced staff with strong localleadership and direction. Patients told us they felt safeat the department. Systems and processes worked tokeep people safe and give them the most appropriatecare and treatment. Staff were caring andcompassionate. Patients said their privacy and dignitywas preserved and they felt treated as individuals.

Staff were dedicated to their patients and their service.They were committed to making improvements andlistening to patients. There were few complaints madeto the service, but those that were made wereaddressed and learned from. There was an open cultureamong staff where any care or treatment or avoidableincidents were discussed and ways to improve wererecognised and implemented. The morale in thedepartment was affected, however, by uncertaintyabout the future of the hospital. Staff felt this was nothelping with local recruitment of nursing staff.

Patients we met described the service as “excellent”,said: “I have no complaints. They have been absolutelywonderful”, “I feel treated like a person here and like Ireally matter to these staff”, and: “I’ve been here anumber of times and with my kids too, and the care hasbeen first class. Nothing but praise for these staff. Theywork really hard and it’s not always easy for them.”

From raw data sent to us by the hospital trust, we sawthe department had breached the Government’sfour-hour waiting time target on occasion. The data didnot support the reason for these breaches, but staff

Accident and emergency

Good –––


confirmed it was mostly due to their not being anavailable bed for the patient to be discharged into.There was no evidence this was due to staff in A&E nottreating the patient in good time to facilitate theirdischarge. There had also been no specific increase inpatient numbers attending A&E in the recent wintermonths. The busiest months in 2013 were in thesummer period.

Are accident and emergency servicessafe?

Good –––

Safety and performanceA&E department staff knew when and how to report andinvestigate incidents. All staff were trained in using theinternal incident reporting system. Temporary (agency andbank) staff would be supported to report incidents if theydid not have access to the electronic system. Staff at sisterand above level had been trained in incident investigation,and training records supported this. There were regularstaff meetings in the department where incidents wereraised and discussed. Minutes were produced for staff whodid or were not able to attend. Action plans from incidentswere produced and staff were updated on the progress ofactions. A recent analysis of incident reporting by thematron and a review of staffing levels across the trust, haddetermined the need for an increase in nursing staff. Thishad been approved and new staff were being recruited.Agency and bank staff were being used in the meantime toincrease the nursing staff coverage. We saw an incidentreported in February 2014 about a lack of equipment over aweekend and equipment being not clean. The incident hadbeen reviewed; the member of staff who had made thecomplaint had been shown where to locate equipment,and the equipment cleaned “from top to bottom.” Staffresponsible for the cleanliness of the equipment had beenalerted to the issue.

People were protected from abuse. Patients who came tothe A&E department were screened on arrival by thereception staff. The reception staff told us they would alertthe clinical staff if they were concerned about the wellbeingor safety of a patient or anyone accompanying them whocould be vulnerable. The department had a See and Treatnurse who would review patients as a form of triage shortlyafter arrival. Vulnerable patients were highlighted to oridentified by the See and Treat nurse or by reception staff ifthey were known to the department already. They werethen taken to a cubicle if possible or to a quieter area of thedepartment.

Staff knew they had a duty to raise an alert if they wereconcerned about the safety of any patient or someoneaccompanying them. They had been trained to deal with


Good –––


suspicions of abuse. Training records showed almost allstaff, including housekeeping staff, were trained insafeguarding vulnerable adults, and this was a topic for allnew staff at induction. Staff were able to tell us how theywould recognise signs of potential abuse and how theywould report this to safeguarding teams.

Learning and improvementThe department learned from auditing its performanceagainst national benchmarks. We reviewed a number ofaudits about this hospital from the College of EmergencyMedicine (CEM). We saw the hospital had improved manyof its results for measures such as giving pain relief,admitting patients to hospital, and getting patients to x-ray.Most of the results for audits were in line with nationalaverages. We asked a lead consultant how the departmenthad responded to poor results from an audit from the CEMin relation to pain relief for patients coming with asuspected fractured neck of femur (hip). The departmenthad initiated a pathway for these patients, which waslinked to approved national clinical guidance. Auditsshowed the administration of pain relief in a timely waywas now much improved.

Systems, processes and practicesStaff were following standard operating procedures andmedicines practice guidelines. The medicine guidelines fornurse practitioners were up-to-date and availableelectronically on the trust intranet. Any updates weremanaged centrally and staff were made aware of changesor amendments.

Treatment was given in the best interests of the patient. Ifan unconscious patient was admitted any treatment wasprovided in their best interests and in accordance with thelaw. For patients who were not able to provide consent ordid not have people to speak for them, A&E staff had accessto an Independent Mental Capacity Advocate (IMCA).However, there were no advertisements for advocacyservices for people who needed another person to speakfor them or with them. The reception staff were not awareof how to guide people to an Independent Mental CapacityAdvocate (IMCA), but the nursing staff had contact details.

Infection controlThere were adequate infection control processes andpractices. There were clearly indicated hand-washingfacilities in the department including hand-sanitising gelsplaced in the right areas. Staff had enough personalprotective equipment including gloves and aprons. Nursing

staff were wearing standard uniforms and all staff we sawwere adhering to infection control protocols (such as being“bare below the elbow”, without nail varnish, and wearingminimal jewellery). We observed the cleaner in thedepartment working to cleaning schedules in the regularbut also harder to reach areas. The department was clean,well-organised to help effective cleaning, and fixtures andfittings were maintained. The chairs in the waiting roomswere showing signs of age and wear and tear. Thecoverings were damaged in places. This made keeping thechairs clean and preventing the spread of infection difficult.The matron told us the waiting area was due to be updatedin spring 2014 and the chairs replaced.

EquipmentWhere needed, areas of the department were locked andsecure. Medicines, equipment and consumables were inlocked rooms or cabinets. The keys were held by a seniormember of staff and handed over responsibly at shiftchanges. Staff explained how the codes for the key-padentry systems were changed regularly for security reasons.There was some equipment stored in corridors in adepartment that had little available space. However, theseareas had limited footfall from patients and had beenrisk-assessed as being safe for this storage. Wheelchairsand trolleys were able to move safely through thedepartment as needed.

Monitoring safety and responding to riskStaff were supported to raise concerns without fear ofreprisals. All the staff we spoke with said the matron putpatient safety first. Staff said they were encouraged tospeak up about any concerns and were reminded in staffmeetings of the importance of this. We read the hospitaltrust’s whistle-blowing policy dated August 2013. Thispolicy outlined the duty of staff to report concerns, howthey would be dealt with, and the support available to staffwho raised concerns. The policy went on to describe theprocess for managers who were dealing with complaints.

Patients in the A&E department were monitored on aregular basis for any deterioration. We saw patients whoneeded to be were being monitored by electronicequipment checking, for example, their respiratory rate,peak flow, and arterial blood gases. Patients were alsomonitored for any changes to their vital signs, verbal, eyeand motor response rates.

Consultant staffing levels were planned effectively. In 2013the department had recognised additional consultant


Good –––


cover was needed. This had been arranged by September2013. Department information stated the coverage wasnow organised so there was emergency departmentconsultant presence from 8:30am to 8pm on weekdays(two consultants with a five-hour overlap in the middle ofthe day) and 12:30pm to 8pm on weekends. We saw therotas for five weeks of 2014 chosen at random and sawthese shifts had been organised.

Nursing staffing levels were planned effectively, althoughthe department was carrying a 12.5% vacancy rate at theend of December 2013. These shifts were being coveredmostly by regular bank and agency staff, although staff toldus they were not always filled, and the matron said: “wemanage”. Staff said they made sure they took their breaks,although sometimes they had foregone these when thedepartment was particularly busy. The departmentbudgeted for just under 48 nursing positions (whole-timeequivalent). Nursing staff told us this had been recentlyincreased following a review of incidents linked to staffshortages. On our unannounced visit to the department onSunday 2 March 2014, the department was fully staffed asplanned. We were told one of the staff-grade doctors (alocum) had not arrived for their shift on the previousmorning and the medical team of three doctors wasreduced to two. The lead consultant said the departmenthad “coped well enough” but doctors had not been able totake breaks at times and there was little time foradministration and teaching.

The department had cover from either four or fivestaff-grade doctors each day of the week. There were twoor three doctors on shift together during the day and oneovernight. There were also two or three senior houseofficers (junior doctors) on duty on weekdays across thehours of 9am through to 6am the following day, and 9am tomidnight on weekends. The doctors were supported by arange of nursing staff and clinical support workers. Thematron was in the department most days, and worked oneshift on exchange with the matron from the John RadcliffeHospital in Oxford. Either the matron or one of the seniorsisters were on duty over the weekend.

Are accident and emergency serviceseffective?(for example, treatment is effective)Not sufficient evidence to rate

Using evidence-based guidanceThe department used national recognised clinicalguidance to deliver care and treatment to meet people’sneeds and give good outcomes. For example, thedepartment followed an approved pathway for hipfractures. People who had suffered a stroke were cared forquickly and placed on the agreed stroke care pathway. Thepathway had been developed in line with the latestNational Institute for Health and Clinical Excellence (NICE)guidelines for stroke care. We reviewed the stroke pathwayand saw records showing quick identification and how thepatient was managed. The stroke pathway for patients notsuitable for thrombolysis showed the duties and decisionsin the first and second hours after admittance to thedepartment. This included ensuring staff did not admit thepatient to the Emergency Assessment Unit, but straight tothe Acute Stroke Unit.

The department recognised the need for people tomaintain their nutrition and hydration, and have effectivepain relief. The department had scored 91% for the mostrecent audit (December 2013) of nutritional assessmentscores being recorded for patients. Patients we met on ourvisits had been offered pain relief. The charts we reviewedshowed this had been done for the patients in thedepartment. We observed staff regularly checking withpatients who had not wanted pain relief if the situation haddeteriorated. The patients we met had all been offered adrink and, if they had been there during a regular mealtime, they had been given sandwiches. Carers were alsooffered a drink and there were drink and snack vendingmachines in the department which were in working order.

Performance, monitoring and improvement ofoutcomesThe department recognised the pressures it often facedand was proactive in looking for ways to be more efficient.There was a See and Treat service where patients weretriaged as soon as possible after arrival. Notes were madeabout why the patient had come to the A&E departmentalong with some preliminary observations and simple painrelief prescribed. People were referred to their GP where


Good –––


this was an alternative solution. There was a recentlyintroduced Rapid Nurse Assessment (RNA) system wherepatients who presented at the hospital who were moreseriously unwell (referred to as “majors”) were quicklyhanded over to an emergency nurse practitioner (ENP) bythe ambulance team. These highly-trained nurses wereable to provide intervention care to seriously unwellpatients as part of the RNA system. Two ENPs covered a15-hour period each day. We spoke with ambulancepersonnel and they were able to confirm the handover tothe hospital team was now “a lot better” and “muchimproved” following the introduction of the RNA system.The rapid assessment target for the nurse team was tocarry out observations and any chest x-rays if neededwithin 15 minutes of arrival and, records showed, for themajority of patients, this target was met.

Staff, equipment and facilitiesMandatory training for staff was up-to-date. The mandatorytraining required for staff in various roles was appropriatein both subject and frequency required. For example, firesafety was refreshed following induction every year, as wascardiopulmonary resuscitation (CPR) training. Health andsafety and safeguarding, for example, were updated everythree years. We saw records for mandatory training fornursing staff and these were clear and comprehensive. Thehospital used an electronic staff record system where staffwere alerted to any training due for updating. Seniornursing staff were able to oversee training and ensure staffwere completing their required courses. We saw recordsshowing nurses who were able to administer pain relief hadbeen tested and their competency assessed.

There was good training and support for doctors within thedepartment. We met two junior doctors who told us theteaching was good. One told us they had received “the bestteaching so far” in the A&E department. Consultant coverwas provided by a rotation programme for doctors workingat both the Horton Hospital and the John Radcliffe Hospitalin Oxford. A consultant told us there was a “goodrelationship” among the consultants and they had regularmeetings and had organised educational support awaydays. There was a GP service arranged by another healthcare provider. Staff said this alleviated pressure on staff andthe services had a good relationship.

There was a lack of specific training for supporting peoplewith cognitive impairment in emergency departments. Staffsaid they had not had specific training in caring and

supporting people with dementia or a learning disability.There was no automatic screening for patients todetermine if they had dementia or a learning disability andmay have additional needs. There was no evidence staffwere not treating people with cognitive impairmentswithout empathy and consideration, but they had not beenspecifically trained to recognise the signs and risks.

New and temporary staff were supported and mentored.Temporary (locum, agency or bank) staff went through aninduction when they first worked at the department. Wesaw the induction process and approval forms werecompleted when any temporary staff were engaged. Thisincluded verification of their professional registration.Student nurses were able to work in the department intheir second year of training and most staff in A&E hadbeen trained to mentor and support student nurses. Due tothe complexity of patients and how busy the departmentcould get, there were a maximum of three student nursesworking at any time.

Children’s emergency services were effective, although didnot meet some aspects of guidance around facilities orstaffing. The Royal College of Paediatrics and Child Health(RCPCH) Standards for Children and Young People inEmergency Care Settings (2012) states there should be oneor more child-friendly clinical cubicles or trolley spaces per5,000 annual child attendances, and children should beprovided with waiting and treatment areas that areaudio-visually separated from the potential stress causedby adult patients. The current facilities in the emergencydepartment did not meet this guidance. However a seniorstaff member told us this was under review.

Staff in the emergency department told us the departmenttreated approximately 8,500 young people per year. Therewas no separate waiting area for children but there was awell-equipped play area children could use to wait fortreatment. There was an area in the two-beddedresuscitation room which had appropriate equipment totreat children. There were two treatment bays in theemergency department which staff said they would “tryand use exclusively for children” but they would not “delaycare just to wait for one to be free.” A parent with asix-year-old child told us they were “very satisfied” with theservice as it meant they “didn't have to travel over an hour”to access the emergency department in Oxford. Anotherconfirmed their child had been given timely pain relief onarrival.


Good –––


The standards also identified there should always beregistered children’s nurses in emergency departments, ortrusts should be working towards this. Staff should, as aminimum, be trained in paediatric life support. There wereno paediatric trained nurses in the emergency department,although all staff had received recent training in basicpaediatric life support. The majority of medical staff spokenwith were trained in advanced paediatric life support andhad level 3 child protection training. However, staff hadaccess to specialist advice and support via the paediatricnurses on the children’s ward at the hospital. A senior A&Estaff member told us “it can be challenging in croup seasonfor staff like junior nurses.” There was weekly paediatrictraining jointly between the emergency department andpaediatric consultants on the children’s ward. Staff told usmiddle grade doctors did not get the teaching sessions asthey cover the emergency department. A trainee GP told us:“I have great support as have access to the paediatricresident 24-hours-a-day, seven days a week.” Another staffmember said they were “happy” with the level of paediatricsupport to the A&E Department and the service “feels safe.”

In the emergency department a parent told us: “Staffingseem good here as we haven't had to wait long.” They saidpain relief medication was “given quickly to my daughter.”Another said: “We are very happy with the service.”

Multidisciplinary working and supportThere was good multidisciplinary team support for andfrom staff of all disciplines. Shifts in the A&E departmentwere covered by consultants who were either presentduring the times the department had identified as usuallythe busiest or most risky, or consultants were on call fromother parts of the hospital.

Patients were given support from different teams to meettheir needs. The lead consultant told us patients who werevulnerable or did not have support they would haveneeded at home would be admitted to a ward (usually theEmergency Assessment Unit) until support was organised.They would remain there under the care of the A&E doctor,and a visit from an occupational therapist would bearranged as soon as possible. There was otherwisetelephone support to staff from social services 24 hours aday.

Are accident and emergency servicescaring?

Good –––

Compassion, dignity and empathyPatients were treated with consideration and compassion.Patients we met and talked with at both our visits to thehospital and the public listening events were positiveabout the care they received. The attitude of staff wasdescribed as “first class”, “very good”, “they have been reallykind”, and “impressive.” Many patients we met hadattended the department before and said this was the caseon each visit. There were cards and letters on display in thedepartment thanking staff for their care and support. Mostof the cards thanked staff for their “kindness.”

Staff treated patients and one another with respect. Adoctor working in the department told us the best thingabout the department was “the experienced caring nurses.”A patient told us they felt “like a person” at the HortonHospital and on a number of recurrent attendees said theyhad always been well cared for. A parent spoke positivelyabout the support they received in the treatment of theirchild. They said the consultant they saw was "willing totake the time and listen to me." Patients we met werecomplimentary about staff and said staff exhibited all thecharacteristics they would want. This includedcompassion, respect and a consideration of equality anddiversity.

Patients were given privacy and dignity, although therewere some shortcomings in this area. Some of the way theenvironment was arranged was not adequate for goodprivacy and dignity. This had been recognised by staff andplans were in place to improve this. Patient treatment bayshad curtains around them, and we observed staff usingthese at all appropriate times. Other rooms had doorswithout glass to avoid people being treated being seen byothers. The issues we observed were around patientsentering the department from the ambulance bay andtherefore likely to be on trolleys, and possibly more acutelyunwell or injured. Other patients and those accompanyingthem sat in the main waiting area were able to see patientsbrought by ambulance arrive and this was not good forpatients arriving or those waiting. If there were no availablebeds, patients would have to queue in the corridor. Thematron for the department explained how new permanentscreens were to be erected to obscure the view in futureand a new route for x-ray patients was being designed to


Good –––


avoid them moving through the waiting room area. On ourunannounced visit there were two patients in the corridorfrom the ambulance bay. Portable screens were being usedaround the patients and staff were present with them at alltimes. We observed they were only in this position for amaximum of 15 minutes.

Involvement in care and decision makingPatients and their carers were involved in any decisionsabout their care. The patients we met said they were askedfor their consent for any procedures or tests. They said theyhad been able to ask questions about anything they werenot sure about, and staff were patient and well informed.The department had scored 100% in the most recent audit(December 2013) of consent decisions being recorded inpatient records.

Trust and communicationPatients were supported by good communication. A seniornurse we met in the department told us “communication iseverything in A&E.” They said: “I’m aware just how muchvalue there was in just keeping people informed.Sometimes that’s all they ask and we have to not forgetthat in what can be really busy shifts.” A patient and theirrelative who had been in the department for six hourswaiting for admission to a bed said they were keptinformed. The patient said staff “have been checking on meall the time and I feel I’m in good hands, although I wouldrather not be here.” We observed staff caring for this patientand they talked with them clearly and checked if there wasanything they wanted to ask at that time. They told thepatient when they would be coming back to carry out moreobservations and said the patient must “not hesitate to useyour call bell if you want anything before then or don’t feelwell.” They checked the patient had enough fluids, hadbeen given something to eat, and made sure the relativewas comfortable. We observed patients and peopleaccompanying them being informed about waiting timesand the reasons for any delays or increases to waitingtimes.

People with different communication needs weresupported. The department had a hearing loop in thereception area. There was access to a translation serviceand staff on duty knew which of them spoke otherlanguages or could communicate in different ways. The

lead consultant said they had used the translation servicebefore and it had been “very successful”. There wassometimes a longer wait for more unusual languagesspoken, but rarely had this been more than 30 minutes.

Information was available in writing for people to takeaway or see when they visited. There was a large leafletselection in the waiting room and posters on the walls. Thisincluded telling people about any conditions they mighthave or be concerned about. There was information aboutmaking a complaint or how to contact the Patient Adviceand Liaison Service (PALS). There were results from patientsurveys displayed on the walls.

Emotional supportThe department had a small room available for holdingprivate conversations with patients and relatives. Therewere other rooms available for providing privacy topatients. One room was set aside as much as possible forpatients who had mental health needs or were seen as arisk to themselves from deliberate self-harm. The staff hadworked hard to ensure the risks of the environment were assafe as they could be with otherwise no purpose-designedroom available. If a patient was at a perceived significantrisk, they would be accompanied by a trained member ofthe security team at all times. Patients who weredeliberately self-harming or had other psychiatric problemswere generally admitted to the Emergency Assessment Unitovernight for their safety until they could have a psychiatricassessment. They would be admitted under the care of theA&E doctor.

Support for patients with mental health needs was notadequate at times. Staff said they had a good link to amental health nurse between 9am and 3pm. Outside ofthese hours the service was provided by another providerand described as “limited at best” by one of the senior staff.

Are accident and emergency servicesresponsive to people’s needs?(for example, to feedback?)

Good –––

Meeting people’s needsThe department had adapted to meet many of the needs ofthe local community, although not all services were beingprovided. There was good physical access to the


Good –––


department for people with a disability, whether physicalor sensory. The department had the facilities for providinglife-saving care and treatment, including a two-beddedresuscitation area which was fully equipped. There wasprovision in the cubicle areas for people accompanyingpatients to sit down. Patients said the trolley beds werecomfortable and staff made sure bed rails were used withpatients’ permission in order to keep them safe from harm.

Some services were not available at the hospital. Patientsand staff we met said they were concerned about therecent removal of emergency surgery from the hospital.Patients who arrived at the A&E department and werefound to be requiring emergency surgery were transferredto another hospital providing this service (generally theJohn Radcliffe Hospital in Oxford). A number of patients wemet at our listening event said they were not consultedabout this and were concerned about the risks this mayhave for the community. The trust told us about thecommunication exercise undertaken to inform all internaland external stakeholders about the decision and rationaleto remove emergency abdominal surgery from the hospital.This involved meetings with the Community PartnershipNetwork.

There had been some changes made to improve pressurewithin the department. This included additional capacitycreated by converting one ambulatory bay into a mixed-sexassessment area with five trolley beds. The ambulatory baywas moved to another area. Additional staff were recruitedand equipment purchased to enable the new bay to beoperational in November 2013.

Vulnerable patients and capacityPatients with a learning disability were supported by caringstaff. The nursing staff knew some patients with a learningdisability may arrive with a “hospital passport”. This was adocument a person with a learning disability may bringwith them into a hospital to explain in writing and pictureswhat staff might, should, and must know about them. Staffsaid they knew to read and take account of the informationin the hospital passport and to treat the person in a calmenvironment. They said they knew people with a learningdisability were often scared of hospitals and they would tryto put them at their ease as much as possible. They saidthey would be guided by the patient’s carer.

Access to servicesThe pressure on bed space meant waiting times in A&Ewere sometimes not meeting targets, and this impacted on

patient care. We know from evidence about the trust, theA&E departments across whole trust had regularlybreached the Government’s four-hour waiting target for95% of patients to be seen and discharged from thedepartment (to home or a ward, for example). Thestatistical evidence we received from the trust for the year2013 showed just 1% of children being treated in the A&Eunit breached the four-hour waiting target. However, of theadult patients coming to the department, 6% breached thefour-hour waiting time target (against the governmenttarget of 5%). However, in both March and April 2013, therewere 12% of all adult patients breaching the four-hourwaiting time target. In January 2014 this figure was also12%. Otherwise, the monthly data was all single-figurepercentages.

The breakdown of the reasons for breaches has not beenmade available by the trust. We know from talking withstaff and stakeholders, the reasons for the target not beingmet most of the time were predominantly a result of bedspace being available in the hospital and therefore notattributable to the performance of A&E staff. The patientswe met on our visits who were waiting over four hoursconfirmed they were awaiting an available bed in the rightward.

Leaving hospitalPatients were given appropriate information when they leftthe hospital. Patients were given a copy of the letter beingsent to their GP. They were encouraged to make sure theGP had directly received the information, particularly iftests needed to be arranged. The lead consultant we metsaid the organisation had learned how the electronictransfer of records to a patient’s GP had proved to beunreliable on occasion. Staff sent the details electronicallyand now gave patients a copy of the letter and a clearexplanation of what they should expect to happen next.Patients leaving the department were also giveninformation on head injury, care of sutures, and woundcare advice. This information contained details on how apatient may feel and advice on what symptoms to look outfor and when to seek expert advice. The department hadaccess via the internet to other approved information forpatients with unusual conditions. Patients admitted onto award from A&E were sent with appropriate records. Thisincluded the treatment already given and any medicationadministered.


Good –––


Learning from experiences, concerns andcomplaintsThe department had a positive attitude towardscomplaints and concerns. The matron had been providingstaff with a summary of complaints for just over a year. Thenumber of complaints was relatively low, with thedepartment receiving 32 since January 2013. Trends withincomplaints had been looked for and any themes werehighlighted. Three staff asked independently of oneanother said the matron for the department wouldregularly inform staff at team meetings of any complaintsmade. These would be discussed and, if there was learningfrom the complaint, staff would focus on makingimprovements. One example of this was increasing levels ofcommunication with patients so when waiting timesbecame longer, patients knew why.

Concerns were listened to and dealt with. One patient wemet at a listening event said they had met a member ofstaff on one occasion who was “less than sympathetic.”They had mentioned this to a nurse before they left thedepartment. They said they had been advised the memberof staff had been an agency worker and they appreciatedhow the nurse apologised for their experience and said itwould be addressed. They said the nurse had told themhow to make a complaint but the patient said they feltreassured by the “assurance from the nurse” and didn’t feela complaint was needed. The issue with information notreaching or being seen by a GP was another example ofcomplaints being heard. The department made surepatients (or their carers) left with a copy of any letter beingsent to a GP and told what to expect if further treatmentwas required.

Are accident and emergency serviceswell-led?

Good –––

Vision, strategy and risksThe vision and strategy for the department at local levelwere clear. Senior staff, such as the matron and leadconsultant had plans and strategies including, for example,improvements to the environment. Staff were proud oftheir department and the care it gave. Most local patientsand most staff said their biggest concern was over thefuture of the hospital and the department. We were told the

closure of the hospital had been suggested and there weremany rumours about this. The trust had told us that thehospital remains as part of their plans. A local group hadbeen formed to campaign for the future of the hospital.Patients said they were most concerned about the possibleclosure of the A&E department and the risks to patients ofneeding to travel to Oxford for emergency care. Threepatients with young children said this was of particularconcern with child-care arrangements. Staff said theuncertainty around the future of the hospital was affectingstaff morale. They were concerned the vacancy rate fornursing staff was high as potential candidates wereconcerned also about the future of the hospital and comingto work in the local area as a result.

The department was aware of its risks. Risks werediscussed at the monthly clinical governance meetings.The existing risks were reviewed and new risks were agreedto be added to the risk register. There was a comprehensiveand clear action plan for the ED. This identified areas ofconcern and actions to be taken to address these. The staffresponsible for the actions were identified and acompletion date was set. Progress against actions wasreported. The action plan looked at the way the widerorganisation affected the ED and problems were sharedand addressed across departments to look for ways totackle problems together.

Governance arrangementsThe department had strong governance arrangements. TheA&E department was part of the directorate coveringemergency medicine for the whole trust. Staff thereforemet with the team that included colleagues from the JohnRadcliffe Hospital emergency department. Clinicalgovernance meetings were held each month and there wasa more focused discussion of the Horton Hospital ED eachquarter. We reviewed the minutes from the January 2014meeting. Attendance was from seven consultants inemergency medicine, one of the two matrons, a consultantnurse, and seven other senior staff attending. The meetingminutes showed good open and honest discussions of, forexample, complex cases where not everything worked as itshould have done. The minutes included pictures of x-raysand scans for unusual presentations. The minutesdescribed the lessons learned and actions taken. Therewas also a review of mortality and any lessons or actionsarising. This included a screening of all deaths in ED andany points to be noted. The meetings covered both theHorton Hospital and the John Radcliffe Hospital which was


Good –––


a major trauma centre, so there was good sharing amongstaff of information and experiences. Any actions wereassigned to a member of the team and these were updatedat the next meeting.

Leadership and cultureLocal leadership in the department was strong. Staff told usand we observed there was strong and committedleadership and support from the matron, the consultants,and the senior nursing staff team. Staff told us they felt partof a team who cared for and supported one another. Wemet a range of nurses from across the whole hospital at astaff focus group who were band 5 and 6 grade. Each ofthem highlighted to us how the support of their colleaguesand the culture within the hospital was the reason theycame to work.

Wider leadership and support was not visible to all staff. Amember of staff said members of the executive team were“rarely seen in the department.” Most staff told us they felttheir voice was not heard among the wider trust, eventhough their matron and senior staff spoke “loudly” andwere “out there promoting us to anyone who will listen.”

Patient experiences, staff involvement andengagementPatients’ views were sought and taken into account. Whenwe were visiting the A&E department, we saw staff givingpatients the Friends and Family Test response cards, andasking if they would complete them. The Horton HospitalA&E department had done well with its responses to thetest with the majority each month much higher than theEngland average in April to December 2013. In July 2013, forexample, the response rate was 25.3% (England average10.4%). Of the 480 responses, 456 people said they would

be “extremely likely” or “likely” to recommend thedepartment to their friends and family. Only six people saidthey would be “unlikely” or “extremely unlikely” torecommend the department. In November 2013, theresponse rate was 21.5% (England average 15.2%). Of the322 responses, 307 people said they would be “extremelylikely” or “likely” to recommend the department to theirfriends and family. Only two people said they would be“unlikely” or “extremely unlikely” to recommend thedepartment.

Learning, improvement, innovation andsustainabilityStaff were well supported and understood their roles andresponsibilities. Nursing staff appraisals were at 91% for theyear to the end of March 2014, which was above the trusttarget. Regular and locum doctors we met said they feltwell supported and part of the team.

The department responded to shortcomings in internalchecks and audits. Staff had recently found there wereoccasions when doctors were not double-checking theprescription of medicines for patients to take out (known asTTO medicines). This was discovered when the recordswere audited. A new process was developed for TTOmedicines and the problem had been resolved. The matronhad developed an audit regime to regularly and routinelyaudit the department against the Health and Social CareAct 2008 Regulations. We saw the framework for audits tobe undertaken each month. The department was able tobenchmark itself against other departments, such as theEmergency Assessment Unit, and share learning acrossdepartments. Different staff carried out a changing varietyof audits to develop and improve their skills.


Good –––


Safe Good –––

Effective Good –––




Information about the serviceThe Horton General Hospital provided medical care andtreatment for people on three inpatient wards, a renaldialysis day unit, emergency admission unit, and a dayhospital.

We visited the three medical wards and talked with 12patients, two relatives and 10 staff including nurses,doctors, consultants, therapists and support staff. Weobserved care and treatment and looked at care records.We received information from our listening events, focusgroups, interviews and comment cards. We used thisinformation to inform and direct the focus of ourinspection. Before our inspection, we reviewedperformance information from, and about, the trust andthe hospital.

Summary of findingsThe hospital provided safe care. National tools wereused to measure risks to patients and action was takento address identified risks. Staffing levels were regularlymonitored to ensure wards and departments wereadequately staffed. Integrated care pathways forinpatients with diabetes were still being devised. Actionsincluded a business case to bring diabetes inpatientspecialist nurse numbers in line with the nationalaverage as well as early and comprehensivestandardised assessments.

Staff were caring. Patients spoke highly about the carethey received and the kindness and helpfulness of thestaff. Staff worked effectively and collaboratively toprovide a multidisciplinary service for patients who hadcomplex needs. Patient views and experiences weresought by the hospital, by the provision of qualityquestionnaires, and the responses were fed back to staffon the wards. The hospital demonstrated openness toengage with patients and listen to their feedback toimprove the services provided.

Medical care (including older people’s care)

Good –––


Are medical care services safe?

Good –––

Safety and performanceThe hospital provided safe care to patients on the medicalwards. The trust used the Safety Thermometer which is atool to measure and monitor risks to patients. It includedrisks of falls, catheter and urinary tract infections andpressure ulcers. This showed an improvement in thediagnosis of patients experiencing a new venousthromboembolism. The trust was better than the nationalaverage when comparing patients who had suffered falls.The Safety Thermometer highlighted the hospital washigher than the national average for new pressure ulcersdeveloping in patients aged over 70 years. These patientswere also three times more likely to suffer a urinary tractinfection compared with the national average. Nursing staffwe spoke with were aware of the use of the SafetyThermometer and were able to discuss with us learningthat had come as a result of the data. We were providedwith reports which demonstrated the infection control leadnurse audited the numbers of urinary tract infectionsexperienced by patients and training had been provided tostaff regarding aseptic non-touch techniques and handwashing. An investigation had been carried out within thetrust into the numbers of urinary catheters being usedcompared with the number of infections patientsexperienced. The Safety Thermometer demonstrated thehospital was below the England average for the number ofpatients experiencing harmful falls.

Staff gave us clear examples of when they had reportedpotential safeguarding issues. Information regardingsafeguarding, incidents and near misses was reportedthrough the trust's electronic reporting system and staffwere provided with feedback. However, some staff told usthey were routinely provided with feedback while othershad found they had received feedback on the outcomeonly if they had followed the incident up and requestedinformation. Information was provided to staff at handoverand on a printed handover report regarding safeguardingissues for patients currently being cared for on the wards.This showed patients were safe from further safeguardingissues by knowledgeable staff who had been provided withrelevant information.

Learning and improvementA regular meeting took place in the hospital, attended bysenior staff such as consultants, matrons and senior nurses,regarding hospital acquired infections. Electronic reportswere audited and investigations commenced to provide aroot cause analysis with learning actions when necessary.Such investigations had included a full review of thepatients’ care records, medical records and riskassessments to seek a full understanding of reportedconcerns and incidents. This showed the hospital strived toaddress any failings in previous care.

Systems, processes and practicesOn admission to the hospital, either through theemergency admissions unit or directly to the ward,assessments were carried out to identify the care andtreatment requirements of each patient. Full, writtenrecords of the assessment in the medical records werecompleted by the medical staff (doctors). Nursing staff wereprovided with a template to complete a nursingassessment which identified any care and support thepatient required during their treatment. Some wound andmobility care plans had not always been completed fully toinform staff of people’s needs. There was equipmentavailable, and in use, in order to prevent and support thetreatment of patients with pressure ulcers. Support fromtissue viability nurses was provided from the John RadcliffeHospital. This included support for patients with pressureulcers. Staff reported that although the tissue viabilitynurses were based at the John Radcliffe, support wasprovided in a timely manner.

The weekly multidisciplinary meetings for two patientswith dementia care needs whose records we reviewed, hadidentified the need for a best interest meeting. Thisensured that decisions, when they could not be made bythe patient themselves, were made within the legalframework of the Mental Capacity Act 2005. Relatives andrepresentatives were included in this planning and theirviews were sought and respected.

Infection controlThere were signs and instructions for staff, patients andvisitors about hand washing to prevent the risk of crossinfection. The most recent NHS staff survey noted that only50% of staff said hand-washing materials were alwaysavailable. This was worse than the national average results.During our inspection visit we saw hand-washing facilitiesin each area we visited and found that antibacterial hand


Good –––


gel was available throughout all areas for patients, visitorsand staff to use. We observed staff used the hand gel andhand-washing facilities between patient contacts. Patientsconfirmed the staff were thorough with this practice. Theward staff regularly audited hand-washing proceduresamong their peers and displayed the outcome of the auditon the ward notice board. We saw the audits showedcompliance with hand-washing procedures on the wards.The infection control lead nurse for the hospital monitoredthese audits and also carried out their own checks ofhand-hygiene procedures of which records were availablefor us to inspect. We were told one area of learning whichhad come from such an audit, was the appropriate use ofantibacterial gel together with gloves. Staff confirmed theirunderstanding of the way in which to use the gel to reducethe risk of infection.

Monitoring safety and responding to riskStaffing levels on the wards were generally at a level toenable them to provide effective care and treatment topatients. Nurses and care support workers said they weremoved between wards to cover staffing shortages. Staffsaid they did not always feel confident to meet specialisedneeds of patients on the wards to which they were moved.For example, when staff from the paediatric wards weremoved to provide care to patients who had experienced astroke. We observed a meeting, held twice each day in thehospital, which was attended by a senior staff memberfrom each ward where the staffing levels and thedependency and complexity of patients on each ward werediscussed. An assessment was made on where thepriorities lay for providing additional staff cover. Wardmanagers told us when staff were moved from anotherward or when agency staff were covering a shift, they weresupported by the permanent staff on the ward. Thisensured patients were safe and their care managed byexperienced and skilled staff. We looked at staff rotas forsome of the medical areas and found there were gaps inthe duties which had not been covered. Shifts had beenreferred to agencies and bank staff for cover, and staff wereable to update us with the progress of this. The NHS staffsurvey for 2012/2013 identified that 73% of staff workedextra hours. The hospital told us that recruitment of nursingstaff was ongoing to meet the needs of patients by thetrust's own staff.

We spent time on wards talking to patients and observingwhen they were provided with care. Staff monitored skinintegrity, food and fluids taken, medical observations and

the patient’s general condition. Staff were knowledgeableabout the requirements of patients’ care and treatmentneeds and we observed they were kind, patient anddemonstrated empathy and understanding of patients intheir care. Staff were able to describe patients’ individualrisks and how they were being managed.

Staff told us they had received training in the safeguardingof vulnerable adults and children and knew the process tofollow, should concerns be identified, to ensure the safetyof vulnerable people. We saw information was available forpatients, their representatives and the staff on how andwho to report any safeguarding concerns. The trainingprovided to staff included the Mental Capacity Act 2005,and staff were knowledgeable about how this legalframework provided protection to vulnerable patients.

Staff had a handover of information each shift whenimportant information was passed onto the oncoming staff.Staff said these handovers were informative and enabledan opportunity for discussion regarding patients’ care andtreatment needs and any risk factors present. Two studentnurses made positive comments about the learning fromthe handover sessions and how discussions took place toensure patients were in receipt of appropriate and safe carewhich met their needs.

Anticipation and planningAs part of the hospital’s planning, a surgical wardaccommodated medical patients over the busy winterseason. At the time of our inspection the majority ofpatients on the ward required medical care. We spoke withsenior staff who were confident the medical care andtreatment needs of patients were being met as this was ledby the medical consultant under whom the patient wasadmitted. The consultant and doctors visited their patientsdaily although one doctor told us the visits were often laterin the day as the ward was located in a separate area of thehospital to the other medical wards. One nurse said thishad resulted in delays in discharges due to the obtaining oftablets for the patient to take home.


Good –––


Are medical care services effective?(for example, treatment is effective)

Good –––

Using evidence-based guidanceThe hospital provided information regarding theirperformance linked to outcomes for patients. We wereprovided with mortality indicators which were withinexpected range compared to similar hospitals. We alsofound the Dr Foster national mortality report had nothighlighted areas of increased mortality risk.

We visited the ward that took the lead in how the trustprovided care to patients who had experienced a stroke.Nationally recognised stroke pathways were in place whichintegrated the service for patients with the main stroke unitat the John Radcliffe Hospital.

Performance, monitoring and improvement ofoutcomesThe hospital monitored the care of patients who wereadmitted to the hospital having experienced a stroke.Hyper acute stroke patients were not cared for at thehospital but transferred to the stroke unit at the JohnRadcliffe Hospital in Oxford. The staff were confident thatappropriate treatment was commenced within thefour-hour target when patients attended the emergencydepartment. Monthly audits were conducted and we foundwhere targets were not met, an investigation wasundertaken to establish the reasons for this. We saw fromthe audits for January 2014 and December 2013 that onepatient during each month had not been directly admittedto the stroke unit as their GP had admitted them to theemergency medical unit which had delayed the process.For these patients, once a diagnosis had been made, theywere immediately transferred to the stroke pathway andtreatment started promptly.

Staff, equipment and facilitiesStaff made positive comments about their experiences ofworking at the hospital. They said the hospital was a warm,friendly environment and were enthusiastic about themanner in which all staff and departments worked welltogether and as a team.

Clinical Nurse Specialists worked throughout the hospitaland supported ward-based staff to ensure patients withspecific needs, for example, stroke and diabetic care,received appropriate care and treatment throughout theirstay at the hospital.

Staff on the ward which cared for patients who hadexperienced a stroke had been provided with additionaltraining to be able to competently assess a patient’sswallowing reflex. This meant that when the speech andlanguage therapists (SALT) were not available patients didnot have to wait for assessment. An additional SALT hadrecently been recruited and each ward had an allocatedmember of the SALT team to support the ward-based staff.Additional training had been provided to staff to enablethem to support a programme of rehabilitation on theward. There was no access to rehabilitation services in thecommunity and therefore patients stayed on the ward forthis part of their treatment.

Medical cover throughout the week was provided by twospecialist stroke consultants with on-call medical cover atweekends and overnight.

Staff told us they had access to appropriate and suitableequipment within the hospital.

Multidisciplinary working and supportRegular multidisciplinary meetings took place on thewards. These were attended by the medical, nursing andtherapy staff together with the patient and/or theirrepresentatives when appropriate. Detailed records of theoutcomes of these meetings were recorded in detail in thepatient’s records. The delivery of this agreed care andtreatment were not always recorded so that a writtenrecord was available to all parties to ensure continuity ofcare. Where nutritional intake was monitored we foundfluid and food charts had not always been completed.Turning charts to support people to manage their skinintegrity in line with guidelines were not always completed.

We followed the pathway of some patients through thehospital from their admission to the wards. Patients wespoke with were satisfied and confident regarding the careand treatment they had received. We also were able toevidence planning took place around the patientsdischarged and was discussed throughout their stay inhospital. This ensured the discharge was not delayed.

Multidisciplinary teams were involved with patients whenthey prepared to leave the hospital. The hospital’s


Good –––


discharge liaison nurse was positive in their commentsabout the team working both within the hospital and at theinterface of community and hospital services to promoteeffective discharges for patients. Discharge plans werediscussed during the multidisciplinary meetings to ensureappropriate action was taken at an early stage in thepatient’s pathway so that discharges from the ward werenot delayed. For example, when setting up care packagesto continue at home, contacts with external agencies wererecorded and meetings set up for external care providers tovisit the ward to assess the patient.

Are medical care services caring?

Good –––

Compassion, dignity and empathyStaff talked with patients on the wards in a warm, friendlymanner. Care was explained and patient consent soughtprior to carrying out any care or treatment.

Curtains were drawn around beds when care was givenensuring patients privacy and dignity was maintained.Patients had access to call bells and when these were rungthey were answered promptly. Patients confirmed theirprivacy and dignity were respected and most were positiveabout the care they had received and regarding the staffwho delivered that care. Two patients informed us they hadexperienced one member of staff who was abrupt inmanner.

The medical wards we visited during our inspection wereable to provide patients with single-sex accommodation.Information was provided to patients regarding thesearrangements in the hospital information booklet. Onesenior member of nursing staff outlined the procedureshould the pressure on beds mean shared-sexaccommodation would be required. Clear protocols werein place to ensure patients’ privacy and dignity would berespected at these times.

Involvement in care and decision makingThe medical and nursing daily records provided evidenceof the involvement of the patient and their families, whenappropriate, in discussions and decisions about their careand treatment.

Patients told us they had been provided with informationregarding their care and treatment and were able to make

decisions about their care. One relative was positive in theircomments about their involvement and was clear that theiropinion was sought and they felt they and the patient werelistened to by all of the staff.

We observed nurses explained patient’s medication tothem prior to administering it and obtained the patient’sconsent at each stage of the process.

Trust and communicationInformation was available in alternative languages, on thewards for patients whose first language was not English.This included information about how to make a complaint.There was also access to an interpreter service by theprovision of an interpreter to come to the hospital orthrough a telephone service. Staff gave examples of whenthis had been used.

For patients who were hard of hearing, a hearing loopsystem was available on some wards and informationcould be provided in an audio format if required. Forpatients with visual impairment, information was availablein large print and braille. While these formats were notreadily available on the ward, administration staff we spokewith were informative and knowledgeable about how toobtain these resources.

Patients and their relatives were provided withopportunities to feedback their views and experiences ofthe hospital through quality monitoring surveys on eachward. Several patients we spoke with told us they plannedto complete these as they had been so pleased with thecare and treatment they received from the nursing staff onthe ward.

Emotional supportPatients and those who cared for them were given timeand space to make decisions about treatment or theirfuture. There were private rooms available for discussionsabout end of life or palliative care.


Good –––


Are medical care services responsive topeople’s needs?(for example, to feedback?)

Good –––

Meeting people’s needsStaff were proactive in meeting the needs of patients in thehospital. One consultant was due to see a patient in theoutpatient department, but they had been admitted tohospital. The consultant visited the patient on the ward sothat they did not miss their appointment or have to attendthe hospital again following discharge.

Vulnerable patients and capacityWe spoke with staff regarding the care of patients withdementia. Staff told us they nursed patients with dementiaon the acute medical wards but were not always able toaccess additional staff to support the patient. We weregiven an example of how this had impacted on the patientthemselves and on other patients as their level of confusionhad risen. We found patients with specialist needs, such asdementia, were highlighted at the staff meetings each dayand additional resources made available on theappropriate wards if possible. This showed the hospitalstrived to provide appropriate support and increasestaffing levels when possible, although this was not alwaysachieved. Additional training had been provided to staff onthe wards to ensure they were competent andknowledgeable when providing care to patients withdementia. A link nurse had been identified on each ward totake the lead role regarding dementia care and staff werepositive in their comments about the support they and thepatients received from the dementia link nurses

Access to servicesThe hospital had taken action to meet the predicted needsof the local population. For example, one of the surgicalwards was reconfigured to enable the admission ofadditional medical patients during the winter monthswhen it was recognised higher numbers of medical patientsrequired care and treatment.

A process had been put into action to increase theavailability of medical beds by discharging patients to theday centre while they were waiting for medication to takehome or transport. This meant the hospital was providing

an earlier opportunity for someone else to be admitted tothe ward. We spoke with staff in the day centre, on thewards and the discharge liaison nurse who all consideredthis was working well. One patient accessed this serviceduring our inspection and they were satisfied with theservice provided to them. They spent approximately twohours in the day care unit while waiting for discharge home.The nurse on the day care unit was able to spend time withthem to ensure all arrangements were in place for whenthey got home and discussed all their medicines with them.

Where possible patients were admitted to medical wardsthat specialised in their condition. For example, Oak wardspecialised in the care of patients with a stroke as well asacute medical conditions and Laburnum ward for patientswith cardiac and respiratory conditions. When the amountof available beds were limited on the appropriate ward,patients were admitted into another medical ward andthen transferred when possible and appropriate. The wardstaff liaised and discussions took place at the daily staffingmeetings and multidisciplinary team meetings to ensurepatients were situated appropriately.

Patients with specialist care and treatment needs did notalways have access to specialist services to enhance theirrecovery. For example, the week prior to our inspectionthere had been no cardiologist available at the hospital asall three consultants had been on leave. Patients requiringthis service had been treated by the acute medical team oncall. There had been no diabetic specialist consultant inpost for a period of time which meant the acute medicalteams provided care and treatment to patients withdiabetes. This had been recognised by the trust and adiabetic specialist consultant had been appointed on theweek of our inspection. Inpatients had access to a visitingdiabetes specialist nurse while more were being recruited.Staff informed us this person was approachable andhelpful but at times working under pressure.

Leaving hospitalInformation for patients regarding the discharge andassociated procedures was available on the wards in theform of leaflets and also specific information for individualswas provided. The staff were proactive in monitoringdischarge times and each ward had a whiteboard whichclearly highlighted the planned discharge date so that anydelays could be seen at a glance. We heard from staff andpatients that patients had been delayed in leaving thehospital for a variety of reasons. These included a lack of


Good –––


appropriate placements in the community, rehabilitationplacement availability, high family expectations andcommunity care not being readily available. This led topatients remaining on the medical wards when they weredeemed fit to be discharged which affected the availabilityof beds to admit poorly patients into.

Learning from experiences, concerns andcomplaintsThe trust had found discharges had been delayed in a highpercentage of patients, based on their auditing in the past.As a result, a discharge co-ordinator had been appointedand had been in post for almost one year. The latest auditfigures indicated the delayed discharge figures wereconsiderably lower than previously.

Information was available on the wards regarding how tomake a complaint or raise a concern. The Patient Adviceand Liaison Service (PALS) provided a confidential servicefor patients, relatives and carers. There were posters andleaflets containing their contact details availablethroughout the hospital.

Are medical care services well-led?

Good –––

Vision, strategy and risksDuring discussions we had with staff it was evident theywere proud of their hospital and were committed andpassionate regarding the care provided to patients. Staffand patients expressed concern at the relocation of someservices to the John Radcliffe hospital which was locatedsome twenty miles away. People told us they had not feltconsulted or listened to by the trust regarding thesechanges.

Governance arrangementsDuring our discussion with senior managers, ward-basedstaff and clinical specialist staff it was clear that monitoringarrangements were in place. We saw information onnoticeboards that provided feedback to staff on theoutcomes of audits and governance meetings.

The trust compiled and kept up to date a risk register whichidentified serious patient safety risks and those thatbreached waiting time targets or good practice guidance.The risk register was made available to us prior toinspection and we saw action plans to reduce the

identified risks were in place together with clear dates forreview. This showed the trust responded to and addressedrisks to patients and visitors to the hospital whilecontinuing to review improvements.

Staff told us they were aware that care-planning recordsrequired improvements. Work was ongoing to review thedocumentation across the medical wards and in theemergency admission unit to bring consistency in thetemplates used and improve its quality and effectiveness.

Concerns had been raised regarding falls sustained bypatients in the hospital. Falls were recorded through theelectronic reporting system and were audited at a seniorlevel. As a result of the monitoring of these incidentsadditional equipment had been requested and provided,for example alarmed mats to alert staff to patientsassessed at risk from falls. The Rowan Day Unit offered careand support in the form of physiotherapist-led groupsessions to outpatients who were at risk from falls. Thisservice had recently been available to patients from thewards to attend as part of their ongoing care andtreatment. This demonstrated that incident reporting wasmonitored, solutions sought and good practice transferredacross departments.

Leadership and cultureMedical and nursing staff were dedicated and committedto providing good patient care, and to improving care. Stafftold us they felt supported by their immediate managersand could approach them with any concerns and felt theywould be listened to. Staff were positive in their commentsregarding the matron, who they found approachable andwho visited the wards regularly.

It was evident that a clear understanding of theorganisational structure was in place at the hospital.However, staff felt that support from the trust’s seniormanagement team and board, who were located at theJohn Radcliffe Hospital, was not as evident, with some staffexpressing feelings of isolation.

Staff told us there was a lead physician in post at thehospital who was consulted when necessary regardingmanagement issues. The lead physician was allocated twohours each week as management time for this role, out oftheir role as a clinician.


Good –––


Patient experiences, staff involvement andengagementPatient views and experiences were sought by the hospital,by the provision of quality questionnaires, and fed back tostaff on the wards. Information about the ward or

department was displayed in the corridors which meant itwas visible to staff, patients and visitors. This demonstratedopenness by the hospital to engage with patients and listento their feedback to improve the services provided.


Good –––


Safe Good –––





Information about the serviceA range of general surgery was provided, includingorthopaedic, gynaecological and general. Services weremanaged within five clinical services divisions. There werefour surgical wards; G ward (day-case gynaecologicalsurgery), F ward (orthopaedics), E ward (surgery) and aday-case unit which was attached to E ward. The hospitalhad four operating theatres.

We visited all of the wards and the pre-admissionassessment unit. We also visited two of the theatres andthe endoscopy unit.

We talked with patients, relatives and members of staff.These included all grades of nursing staff, healthcareassistants, domestic staff, consultant surgeons, consultantanaesthetists, junior doctors, and senior management. Wereceived comments from people at our listening events,and from people who contacted us to tell us about theirexperiences. Before our inspection, we reviewedperformance information from, and about, the trust.

Summary of findingsThere was consensus among patients, carers and staffthat staff were dedicated and provided compassionate,empathetic care. Processes were followed to reduce anyrisks to patients undergoing surgical treatment. Therewere processes to ensure patients who moved todifferent wards received consistent and safe care andtreatment. Staff made use of the language line facilityand interpreters to ensure patients had goodunderstanding of their treatment and were able to makeinformed decisions. Staff had a good understanding ofthe Mental Capacity Act 2005 which meant patientsreceived the appropriate support to be able to maketheir own decision, or where required decisionsinvolving appropriate people were made in the bestinterest of the patient.

Generally, there was sufficient equipment available tomeet the needs of patients. However, concerns wereexpressed about access to MRI imaging. Patients had togo to the John Radcliffe Hospital in Oxford to access MRIimaging; we were told that difficulties in arrangingappointments meant there was a risk that somepatients’ treatment would be delayed.

We saw good evidence of team working at ward anddepartmental level. However, with some of theclinicians, there was a feeling that despite being part ofOxford University Hospitals NHS trust, the views andopinions of staff at Horton General Hospital were notalways heard.

Surgery

Good –––


Are surgery services safe?

Good –––

Safety and performanceSafety in theatres at the hospital was good. There were 206patient safety incidents (trust-wide) reported by the trust’ssurgical services to the National Reporting and LearningSystem (NRLS) between July 2012 and July 2013. Thisaccounted as a surgical directorate for 34% of all incidentsreported across all specialties. Of these 192 were gradedmoderate, 11 abuses, two severe and one death.

Between December 2012 and November 2013, 35 seriousincidents were reported in surgical services trust-wide.Twenty were in ward areas, four in operating theatres andone in a day case theatre. Of these, two were categorised asnever events. Never events are largely preventable patientsafety incidents that should not occur if preventativemeasures are taken. Neither of the never events occurred atHorton General Hospital but staff throughout the surgicaldirectorate were aware of them and included in the rootcause analysis and lessons learned.

Doctor Foster hospital mortality data showed mortalityrates in surgery at this hospital were not a cause forconcern. The incidence of pressure ulcers, infections,venous thromboembolism (VTE) and falls on surgical wardswas also within the expected range.

As a result of the departure of three surgical consultants inJanuary 2014 the trust had temporarily suspendedabdominal surgery at the hospital. This was done to ensurethe safety of patients. Following this, a review of emergencyabdominal surgery was conducted. This consideredguidance from professional organisations such as the RoyalCollege of Surgeons. As a result, to ensure patient safetywas not compromised, emergency abdominal surgery wastransferred to the John Radcliffe Hospital in Oxford. Aclinician told us the hospital was: “a safer place thanbefore.”

The safety and wellbeing of patients undergoing surgicalprocedures was protected. As is best practice, the OxfordUniversity Hospitals NHS Trust used the World HeathOrganizations (WHO) surgical safety checklist in operatingtheatres. The WHO checklist is a system designed to

prevent avoidable errors. We saw good use of the checklistin the two theatres where we observed practice. Thetheatre staff we spoke with said the checklist was donewell.

Assessments for the risks of pressure ulcer development,venous thrombosis and risks of falls were completed andrelevant action was taken to reduce identified risks. Thisincluded the use of pressure relieving equipment andprescribed anti-embolic stockings both on the surgicalwards and in the theatre complex.

The Oxford University Hospitals NHS Trust had a children’sand adults’ safeguarding policy. Training aboutsafeguarding adults and children was part of themandatory annual training that all staff completed. Staff atHorton General Hospital knew about the policy and wereconfident about reporting safeguarding concerns. However,some members of staff working in the theatre complexwere unclear what process was completed after theyreported concerns.

The security and safety of the theatre suite was acceptable.Access to the theatre was secured with the use of a key-padsystem.

Learning and improvementThe hospital learned from incidents and took action toavoid recurrence. Theatre staff gave examples aboutchanges in practice made as a response to incidents thathad occurred. This included incidents that occurred locallyat the Horton General Hospital and incidents – such neverevents – reported across the trust. Weekly andthree-monthly auditing of the WHO checklists meant thatprocesses to ensure patient safety were being monitored.

On the surgical wards, staff knew about the process toreport incidents. Examples were given where practices hadbeen changed as a result of incidents and complaints. Thisincluded on the gynaecological ward improved processesto ensure patients fully understood the information givento them, so they were fully aware about what to expectduring their treatment.

Systems, processes and practicesThe wards had systems and practices to follow to ensurepatients received consistent and safe care. On the day-caseunit standardised care plans were used to ensure patientsreceived safe and appropriate care. On the orthopaedicward care plans were used effectively to inform staff aboutthe care and support each patient needed which included

Surgery

Good –––


identifying risks and implementing action to reduce theimpact of the risk. Care plans for patients identified at riskof pressure ulcer development detailed the types ofpressure relieving aids that needed to be used. We sawthese were being used.

Track and trigger monitoring forms were used. This meantthat patients had their health monitored at intervalsappropriate to their health care needs.

The surgery lists of the gynaecological day ward sometimeshad cases that required overnight stays. Processes were inplace and followed to ensure overnight beds in the surgicalward were available for these patients prior to their surgerytaking place.

Staff demonstrated a good understanding of theapplication of the Mental Capacity Act 2005 in relation topatients being involved in making decisions about theircare and treatment. We saw, where applicable, bestinterest decision meetings were held, to support thedecision making process. This was demonstrated on theorthopaedic ward where some patients had a degree ofdementia. Decisions about care and treatment were madeafter recorded discussions with the patient, familymembers and relevant health and social care professionals.

Staff were effective at supporting people in making theirown decisions and choices. Staff had a good workingknowledge of the Mental Capacity Act 2005. Training aboutthe Mental Capacity Act 2005 was included in themandatory safeguarding training for all staff. Staffdemonstrated they understood the application of theMental Capacity Act 2005. To demonstrate theirunderstanding, staff on the gynaecology ward described asituation where assessments were completed anddocumented about a person’s capacity to make their owndecisions. This assessment resulted in the decision beingmade that the person, despite having communicationdifficulties, was able to make their own decision abouttheir care and treatment.

Patients were supported to meet their nutrition andhydration needs. Nutritional needs were assessed onadmission and plans were in place. Inpatient wards hadprotected meal times, so patients were not disturbed whenhaving their meals. On the orthopaedic ward, where therewere a high number of elderly patients, relatives wereencouraged to support their family members with eating atmeal times. We observed on the same ward that drinks

were available and staff supported patients with theirdrinks at frequent intervals. On the day-case ward, snacks,such as toast and tea, were provided after patientsrecovered from surgery.

Patients’ pain was well managed. There were processesfollowed for monitoring patients’ pain. Patients said thatstaff provided them with pain relieving medicines whenthey needed it.

Infection controlThere were sufficient hand-washing facilities on thesurgical wards and operating theatre complex.Anti-bacterial gels were situated at the entrance and exit toall wards and the theatre complex and on the end ofpatient’s beds. We observed staff washed their handsbetween contacts with each patient. This practice reducedthe risk of cross infection.

Monitoring safety and responding to riskThere were staff in sufficient numbers and skill mix toprovide safe and effective care. The trust had completed arecent review to determine the correct level ofestablishment and skill mix for staff on inpatient wards. Wesaw on each ward a chart that identified the ideal level ofstaffing for each shift, adequate level of staffing and detailsabout what level of staffing would mean patients were atrisk of poor and unsafe care. Staff said they used thisguidance to request extra staff if for any reason staffnumbers indicated patients were at risks of poor or unsafecare. Patients told us there were always sufficient numbersof staff on duty to support them with their needs. Patientsand visitors commented that call bells were answeredquickly.

There was a clinical governance system to monitor qualityand safety. This operated at team level, reporting upwardsto directorate, divisional and trust level. Each directorateand division maintained a risk register and produced amonthly quality report. Risk registers were also discussedand reviewed monthly.

Processes were in place to raise concerns. Staff knew howto raise concerns and were confident that concerns wouldbe managed in an effective and confidential manner. Theyfelt confident their line manager would respondappropriately to concerns they raised.

Surgery

Good –––


Anticipation and planningAnticipation and planning for surgical procedures wasdone well. For non-emergency (elective) procedures thetrust data showed little variance with the anticipatedworkload planning.

On surgical wards planning was done well to reduce anypotential risks to patients. Staff assessed patients promptlyon admission in order to identify risks. If patients required ahigher level of observation the workload was discussed athandovers and organised to facilitate the required level ofsupport. Staff told us that they could request additionalstaff to facilitate intensive monitoring.

Are surgery services effective?(for example, treatment is effective)

Good –––

Using evidence-based guidanceEvidenced based guidance was being followed to delivereffective care. The pre-admission nurses followed the NICEguidance for preadmissions when assessing patients. TheWHO checklist was used in the theatre complex to ensurepatient safety. On the orthopaedic ward staff werefollowing the Falls Safe Project, to reduce the risk ofpatients falling. This project was supported by the followingpartner organisations: the Royal College of Nursing, theNational Patient Safety Agency, NHS South Central, theBritish Geriatrics Society, and the patient safety charityAction Against Medical Accidents.

Performance, monitoring and improvement ofoutcomesWe found generally that patient record keeping was good.On the wards, records were good, with a few gaps, butoverall well completed. Monitoring of patients’ health andwellbeing was completed at the intervals as stated in theirtrack and trigger charts or their plans of care. We sawpatients’ care was reviewed daily and their care plansaltered according to their needs and wellbeing.

Staff, equipment and facilitiesStaff told us they were provided with suitable training tosupport them in meeting the needs of patients, which theywere up to date with. This included training in dementia,falls, infection control. Data that we saw on wardsconfirmed this. Staff all said they were supported by their

line managers and felt able to raise concerns. They saidthey were listened to and concerns were taken seriouslywith action taken as a result. Patients said they wereconfident staff had the skills and knowledge to provide thecare they needed.

Generally there was sufficient equipment to meet theneeds of the surgical patients. We saw equipment forprocedures and monitoring of patients in the operatingtheatres was readily available. Staff told us the requiredequipment for procedures was always available. On thewards there was sufficient equipment available to monitorand support patients. We saw monitoring equipment,pressure relieving equipment and moving and handlingequipment available in suitable numbers. Procedures werein place to ensure all equipment was routinely serviced andchecked. We saw records to demonstrate this wasoccurring.

Clinicians told us difficulties in accessing the MRI scanner atthe John Radcliffe Hospital in Oxford meant there was a riskthat patients’ treatment was delayed. Patients whorequired an MRI scan had to be transported to JohnRadcliffe Hospital because there was no availability for MRIscanning at Horton General Hospital.

Multidisciplinary working and supportThere was good team working and peer support. Cliniciansworking in orthopaedic surgery were proud of themultidisciplinary and integrated approach to caring forpeople with complex needs. The majority of patients wereelderly and had co-existing illness and/or cognitiveimpairment. An ortho-gerontologist (a doctor whospecialises in caring for older people with orthopaedicinjuries) worked on the ward to provide medical input andensure an integrated approach to their care and treatment.There was a multidisciplinary approach to planning thecare, support and discharge for patients on theorthopaedic ward. This included the involvement ofnursing, medical, physiotherapy, occupational therapy andsocial work staff. A liaison psychiatric service had recentlybeen introduced by the trust. This meant support could beaccessed for patients on any ward who had any form ofmental-health need.

Surgery

Good –––


Are surgery services caring?

Good –––

Compassion, dignity and empathyPatient experience of care was good. All patients we spokewith in the hospital told us staff were caring and kind. Weobserved good care on all wards in all interactions.

Patients’ privacy and dignity was respected. We saw thatcurtains were drawn around patients’ beds when personalcare was provided. Ward accommodation was segregatedso men and women were afforded privacy and dignity.Relatives told us from what they observed all patients weretreated with respect and dignity. A relative told us:“Curtains are always pulled round [them] and otherpatients when care is being delivered.” Patients had accessto call bells which they could use to call for assistance. Wesaw these were in easy reach. Patients told us staffresponded promptly when they called for help.

We saw the results from Friends and Family Tests weredisplayed in each of the inpatient ward areas. This showeda high level of satisfaction with the service provided.However the Friends and Family Test did not apply to daycase services. At the time of our inspection there was asurvey being completed by the anaesthetic departmentabout the day case patient experience.

Involvement in care and decision makingPatients felt they were appropriately involved with theircare. All patients we spoke with told us that fullexplanations were given to them by medical staff andnursing staff about their proposed treatment in a mannerthat they could understand. They said consent procedureshad been done well. They did not feel pressurised to makea decision or follow a treatment plan they did notunderstand or were not happy with. Patients with plannedadmissions had appointments with the pre-admissionnurse prior to their admission. Literature about theiroperation or treatment and what to expect when theycame into hospital was provided both in the written formand verbally at this appointment. Patients told us they feltfully informed about their admission and treatment.

On the orthopaedic ward there were some patients whohad varying degrees of dementia illness. Staff involved thepatients in their care by speaking with them in simplesentences and using visual aids to help theirunderstanding.

Relatives of patients on the orthopaedic ward confirmedthey were involved in the planning of their family membersof care. One relative told us: “All care and treatment isexplained to me and to my [parent].”

Trust and communicationPatients said staff were friendly, open, and sensitive to theirneeds. Patients said they were encouraged to askquestions if they did not understand the treatment beingprovided. Staff were able to access a telephone languagelink service to support patients’ whose first language wasnot English. If needed interpreters were employed to assistwith communication. Staff gave examples where they hadused interpreters during the treatment of patients toensure they understood and were able to make informedchoices about their care and treatment.

Information about the trust and the hospital was availableon the trust’s website. This included easy-read informationfor people who had difficulties understanding written word,leaflets about various conditions and what to expect whenundergoing surgery. The website could be translated into anumber of different languages.

Emotional supportPatients and relatives told us they received the supportthey needed to cope emotionally with their treatment andhospital stay. There was a chaplaincy service available forpeople of all religious denominations.

Are surgery services responsive topeople’s needs?(for example, to feedback?)

Good –––

Meeting people’s needsPatient needs were being met. Patients told us they werehappy with their care. They said their needs were being met

Surgery

Good –––


and that all staff were responsive to their needs. Onepatient said “nothing was too much trouble”. Most patientswho had used their call bells when they needed help said,staff always responded quickly.

Vulnerable patients and capacityThere was recognition that a large proportion of theorthopaedic ward included a high proportion of olderpatients, some of whom had dementia. On the orthopaedicward we looked at three care plans for older patients. Theydetailed that the patient had some degree of dementia.There was a structured care plan for people with dementiathat was adapted to meet the needs of the individualpatient. We observed that nursing staff were following theguidelines set out in these care plans when providingsupport to patients.

Patients, relatives and staff said consideration for aperson’s mental capacity was done well. Staff on thegynaecology day ward provided an example where apatient with a learning disability had their capacityassessed to determine whether they had capacity toconsent for their own treatment.

If patients had to be transferred across wards this was donein a way that ensured their needs could be met. Processeswere in place to provide relevant guidance and training tonursing staff on the general surgical ward about the care ofpatients who had undergone gynaecological procedures.This was because in some circumstances patients wereadmitted to the gynaecological ward as a plannedovernight stay on the general surgical ward.

Access to servicesAccess to services was good. Patients told us that therewere no delays with their admission to hospital. Staff toldus there were rarely any cancellations to the surgeryschedule.

Leaving hospitalDischarges from the hospital were well planned. Patientson the general and gynaecological surgical wards told ustheir discharge from hospital was discussed at theirpre-admission assessment and when they were admittedto hospital. A relative told us they had been fully involved intheir parent’s discharge arrangements, which includedensuring the appropriate health and community supportwas in place before they were discharged.

Staff told us that patients’ discharge was planned as soonas they were admitted. They told us that patients were

given information about their surgical procedures beforetheir admission and this included information about aftercare. This was reinforced on their discharge. We saw that anestimated discharge date was recorded in patients’ notes.Most patients had been given information about theirdischarge from hospital and they knew when they wereexpected to be discharged. If needed they had beenassessed by physiotherapists and occupational therapistsand asked about their home circumstances and thesupport available to them. Arrangements were confirmedabout how they would get home.

Another patient had been admitted for a procedure thatwould normally be considered as a day case procedure.The patient told us that following discussions during thepre-admission process, plans had been made for them tobe an inpatient because they did not have the requiredsupport at home for the first 24 hours following surgery.

Learning from experiences, concerns andcomplaintsPatients told us they would feel comfortable aboutcomplaining to staff if something was not right and theywere confident that their concerns would be takenseriously. People knew how to complain. Most people toldus they would talk to staff and some were aware of thehospital’s Patient Advice and Liaison Service (PALS), whichwas publicised on the wards and on the trust’s website.

The hospital routinely captured feedback using the Friendsand Family Test. Staff told us results were regularlydiscussed at team meetings.

Are surgery services well-led?

Good –––

Vision, strategy and risksThere was a clear trust vision and a set of values, whichwere patient focused. Some staff could not say what thevision and values were in relation to the trust but portrayedthe NHS values to provide excellent patient care.

Governance arrangementsThere was a clear governance structure with reporting linesfrom departments through directorates and divisions,ultimately to the trust board. However, some of the clinical

Surgery

Good –––


staff working at the hospital felt that the views andopinions of staff working at the hospital were not heard bythe trust. This included the concerns among the staff aboutthe future of the hospital.

Leadership and cultureMany of the staff we spoke with felt well supported by theirimmediate managers. A clinician told us the hospital was:“a great little hospital.” However, a common theme runningthrough our conversations with staff was that there was alack of local leadership at the hospital. This was becausethe leadership was divided into divisions that ran across allfour sites of the Oxford University Hospitals NHS Trust. Stafffelt this meant at times there were delays to implementingchanges at the hospital or taking hospital-wide decisions.

Patient experiences, staff involvement andengagementPatients’ views and experiences were a key driver for howservices were provided. There was information displayed

showing how the ward was performing and the Friends andFamily Test results. Staff said they felt involved andinformed about patient safety and experience. The divisionthat each ward was aligned to held regular staff meetingswhere all staff could participate. Staff on wards said thatattended or were represented at handover meetings whenshifts were changing.

Learning, improvement, innovation andsustainabilityStaff we met said they felt encouraged within their divisionto learn and improve. The General Medical Councilreported the trust had mostly similar or better thanexpected in results from the national training schemesurvey for doctors in the surgical services provided at thehospital.

Surgery

Good –––


Safe Requires Improvement –––





Information about the serviceThe intensive/critical care unit at the Horton GeneralHospital was a six-bedded unit located a short walk fromthe accident and emergency department and next to thetrauma/orthopaedic ward. The unit was used to care forpeople who needed high dependency care, intensive careor coronary care. There were two beds configured forintensive care of patients needing a ventilator to supporttheir breathing. The unit had two side rooms which couldbe used for isolating patients with an infection, or providingmore peace and quiet or privacy if a patient was at the endof their life.

We visited the unit in the daytime on a Tuesday during themorning and again for a brief visit on a Sunday evening. Wespoke at some length with one of the three patients in theunit on the Tuesday morning and with the relatives ofanother patient. We spoke briefly with a patient on theSunday evening when there were four patients on the unit.We spoke with eight members of staff. These includednursing staff, a critical care assistant, a consultant, and ananaesthetist. We received comments from people at ourlistening events, and from people who contacted us to tellus about their experiences. Before our inspection, wereviewed performance information from, and about, thetrust.

Summary of findingsPatients received safe care, which was compassionate,dignified, and delivered good outcomes. . Mortality rateswere below the national average and below theexpected level for patients in a critical care unit. Thecaring and consideration of staff was good. The patientsand relatives we spoke with praised the nursing andmedical staff highly. Vulnerable patients were wellsupported and staff put the patient at the centre of theircare.

The department was well led at local and senior leveland staff were supported and proud of their work. Therewere some issues with patient discharge not beingtimely or being delayed, but this was due to pressureson beds elsewhere in the hospital. On a national leveldata from the latest Intensive Care National Audit andResearch Centre report showed this problem was notsignificant.

However, the critical care department was not fullyeffective in relation to medical cover. There were skilledand experienced anaesthetists and consultantsattached to the unit, but not all were trained in criticalcare. The lead medical consultant was trained in criticalcare, but this was not their substantive post and theywere not available at all times. There was no evidencethis had resulted in patients being put at risk, but thearrangements did not meet the national guidelines formedical care in intensive care units.

Intensive/critical care

Good –––


Are intensive/critical services safe?

Requires Improvement –––

Safety and performanceThe department had a good record for safety andperformance. The unit contributed their patient data andoutcomes to the Intensive Care National Audit andResearch Centre (ICNARC) so they were evaluated againstsimilar departments nationally. The unit performed well inthe year April 2012 to March 2013 for unit-acquiredMethicillin-resistant Staphylococcus aureus (MRSA) andoutbreaks were low. This was a slight increase however,over the 2011/2012 year where rates were zero. The unitmortality rates were low and below the national average.The ratio for mortality was measured by observed againstexpected deaths. Scores below 1.0 meant there were lessobserved deaths than would have been expected. TheHorton Hospital had a ratio of 0.9 for the 2012/13 year, andalthough this was slightly increased on the result of 0.8 forthe previous year 2011/12, was a good result.

Patients and their relatives felt care was safe. Patients wemet on the ward said they felt safe in the department andwith staff. The ward was locked and visitors had to say whothey were and be identified before coming onto the ward.Staff said they were particularly careful about identificationwhen admitting visitors to a patient who was not able toidentify them (as they were not conscious, had dementia,or were sedated). We observed care being given and sawstaff following guidance in the personal protectiveequipment they were wearing and using. The unit wascalm, well-lit, spacious, clean and tidy on both occasionswhen we visited. The environment was safe and wellmaintained. Staff were seen checking and completingcharts and monitoring patients’ clinical indicators asrequired.

Staff were aware of safeguarding procedures. Staffdescribed some events where they had contacted thesafeguarding team in relation to vulnerable adults and ayoung person they were supporting. There was a flowchartfor use when making safeguarding referrals. This describedwhat patients would be classed as vulnerable, what

matters would constitute possible abuse, and what to do.Staff had been trained in safeguarding vulnerable adultsand children and their experience showed they werecompetent in reporting suspected abuse.

Learning and improvementThe department learned from incidents. Each incident wasreviewed by a member of staff of the relevant seniority.Serious incidents were reviewed by an independent seniormanager. Training in safe patient transfers was provided toall staff following an incident where staff arrived at anotherunit and could not get access to it. Changes had beenmade to medicines storage following learning from anotherincident.

Systems, processes and practicesSecurity of patient records was improved during our visit.When we visited on the Tuesday we saw the patient noteswere being kept in an unlocked filing cabinet at theentrance to the main area of the ward. The drawer was alsolabelled as “patient records”. We discussed the issues withsecurity and safety of these records with the senior staff asalthough the unit was supervised at all times, we thoughtthese records were not as secure as they should be. Whenwe went back to the ward on the Sunday evening, therecords had been moved and relocated to an unmarkeddrawer within the clinical area.

A checklist was available for staff to use to guideassessments of mental capacity. The admissionassessment each patient was given assessed theirpsychological and social needs, and those of their family.Staff said patients who were not able to take their owndecisions due to a lack of mental capacity would have careand treatment given in their best interests. The family or anadvocate for the patient was involved in any decisionsalong with the patient’s medical team.

Medicines managementMedicines and equipment were safely stored. All themedicine cupboards and medicine refrigerator werelocked. The sluice room and equipment room was wellorganised and stock was clearly marked. Equipment wasstored off the floor to help with cleaning routines. Thepharmacist visited the department each day duringweekdays to check on medicines and drug charts. Theemergency resuscitation trolley and the difficult intubationtrolley were checked on each shift and we saw the checkswere up to date and all equipment was present andcorrect.


Good –––


Monitoring safety and responding to riskThe unit had staffing levels that met the needs of patients.If staffing levels were not met from permanent staff, theunit used agency or bank staff to cover absences. Therewas a regular cohort of bank and agency staff, most ofwhom had experience of working on the unit before. Thesenior sister told us if new agency staff came to work on thedepartment, they would be checked for their competencebefore they started a shift. Any staff who did not meet thestandards required would not continue a shift and areplacement sought.

The skill-mix and experience of medical staff was notalways appropriate. Patients who were admitted to the unitcame under the care of a consultant looking after theirunderlying illness who was not based in the department.The unit did not have full-time dedicated intensive caredoctors or consultants. The hospital provided medical careto patients using their team of anaesthetists who spent aday each week supporting the unit with two doctors on callcovering the whole day. Not all the anaesthetists weretrained in critical care medicine. The medical consultantlead for the hospital was trained in critical care, but thiswas one person who was not at the hospital at all timesand had other responsibilities. There was no evidence thishad affected patient care or safety, but it did not followrecommended guidelines for critical care.

There was a low level of experience of some typical patienttreatment and procedures in some areas. The unit had arelatively low number of patients coming for ventilatedcare and treatment. In the previous year this had beenaround 68 patients (around 10% of total patients). Thesenior management of the service were aware of this andthe risks of staff being deskilled from a lack of regularexperience of ventilated patients and were consideringhow best to increase these skills or provide more exposureto this area of care.

There was an escalation policy to be used when the unitwas full. Staff would initially contact the other two criticalcare units in the trust locations. If there were no internalbeds available, staff would then contact the local area bednetwork to see if there was available space at otherhospitals. Additional staff could be drafted in to coverincreasing levels of demand or higher-dependency needs.

This would usually be a relatively low number of staff atany one time as the unit was limited to supporting amaximum of six patients, with only two needing one-to-onenursing care.

Patients had named nurses and doctors caring for them.Each patient, their relatives, and other staff knew who theirnurse or doctor was. Relatives we met said staff alwaysintroduced themselves when they arrived and said whowas responsible for the patient. If there were any staff thepatient or relative had not yet met, they were oftenintroduced by the senior member of the team.

Anticipation and planningThe staffing levels for patients needing critical or intensivecare followed the national guidelines. Patients who wereassessed as level three (for example, patients requiringadvanced respiratory monitoring) were given one-to-onenursing care at all times. Patients who were assessed aslevel two (for example, patients requiring more detailedobservation or intervention) had two-to-one nursing careat all times. The unit also looked after level one patients(for example, patients at risk from their conditiondeteriorating or stepping down before going home or toanother ward) who also received two-to-one nursing care.This meant one nurse looked after two patients. The unithad experienced some recruitment problems recently inappointing to a band five nursing vacancy but this had nowbeen filled. In the interim period bank and agency staffwere being used from a regular cohort of local trained staff.There was also support from the teams at the Oxford sitesand vice versa to cover any unplanned absences amongstaff.

Are intensive/critical services effective?(for example, treatment is effective)

Good –––

Using evidence-based guidanceCare was delivered in accordance with evidence-basedguidance and best practice. Patient records showingmedicines were given as prescribed. We saw records andobserved patients were turned in accordance with goodpractice to avoid skin damage from remaining in the sameposition too long. Patients’ fluid and nutritional intakeswere measured and recorded. Patients were asked


Good –––


regularly if they were in any pain or discomfort and this wasrecorded. Patients were assessed for their risks of falls andappropriate management was in place to support them tomove around safely.

Performance, monitoring and improvement ofoutcomesThe unit monitored its performance and took actions toimprove against identified shortcomings. We reviewedaudits for the department for four weeks in 2013 and fourweeks in 2014. We saw some of the few shortcomings wereas a result of agency staff not completing some paperworkfully. There was an action to discuss this with the relevantmember of staff. Some of the audit results were displayedon the notice board in the unit for patients, staff andvisitors to see. This included audits around hand hygiene,aseptic non-touch technique and ventilator-associatedpneumonia. Scores were all above 90%. Scores for otheraudits such as urinary catheter care, central lines, and useof the tracheostomy care bundle were all at 100% from 25November 2013 to 27 January 2014. There were no reportsof any hospital-acquired infections (such as MRSA orClostridium difficile during this period).

Staff, equipment and facilitiesNew nursing staff were given induction time, training, andmentorship. For new nursing staff, the first four weeks werespent on the unit in a role which was supernumerary to thecurrent staff. The new nurses or critical care supportworkers were therefore not counted among the establishedstaff during this time, so patient care remained provided byexperienced staff. They were also able to have two furtherweeks in the early months of their placement to havesupernumerary time and training. The senior sisterdelivered foundation training to new nursing staff and theircompetency was assessed through an approved frameworkof testing. College courses were available for nursesfollowing registration and junior staff were able to spendtime at the John Radcliffe Hospital or Churchill Hospitalunit for further experience.

The facilities for care were acceptable. The patient area inthe unit was spacious, clean, well-organised and tidy. Staffhad a clear and organised area to work and observepatients. All patients were clearly visible to staff, and thosein the two private rooms could be monitored but also haveprivacy to sleep and be quiet. There was a staff kitchenwithin the unit and close to the clinical area. The kitchenhad no door and the wall did not meet the ceiling. Staff

agreed the placement of this kitchen was not ideal. Weobserved a doctor wash their hands in the kitchen sinkafter clinical contact with a patient. There was also amixed-sex changing room for staff, but staff said they hadadapted to this. We observed the fire doors were unlockedfrom the inside as they should be, and were clearly marked.There was a fire escape route from the rear of the unit thatrequired people to re-enter the building through anotherdoor, and this was also accessible and safe.

Mandatory training for the department was well managedand on track. The unit followed the trust’s mandatorytraining programme and courses were delivered inaccordance with trust policy in terms of type andfrequency. We reviewed a number of mandatory trainingrecords with the senior sister responsible for the nursingstaff. The senior sister’s mandatory training was 100%up-to-date and the date of the expiry of any courses wasclearly shown. The staff managed by the matron hadcompleted 97% of mandatory training to date with onemonth still available to complete training. Staff werealerted through the electronic staffing records of anyupcoming expiry of training certificates and this wasalerted to their manager. Personal developmentopportunities were also available to staff, and this wasdiscussed at annual reviews, or when opportunities arose.

Equipment was serviced and maintained. The unit had anagreed equipment replacement programme which staffsaid was adhered to. They said the equipment wasmaintained and serviced as required and was quicklyrepaired. The mattresses for patient beds belonged to thedepartment and were not used elsewhere. The departmenthad two high-quality mattresses designed for patients whoneeded additional support to prevent pressure ulceration.These would be used for patients who were expected tohave prolonged stays or limited movement.

Multidisciplinary working and supportThe critical care unit had effective multidisciplinaryworking. Patients who were admitted to critical care hadsupport from a consultant anaesthetist during their time onthe ward, and their own divisional consultant. The unit didnot work with a specialist intensive care consultant. Wesaw from records and observation, the consultantresponsible for the patient in critical care or a member oftheir team visited the unit each day. They met with the


Good –––


patient and their relatives if they were on the unit. If thepatient was not conscious, the consultant reviewed thelatest charts and discussed the care with the anaesthetistand the responsible nursing staff.

The unit did not provide an outreach service within thehospital. Many critical care units in England provide anoutreach service where critical-care staff either followed-uppatients who had stepped down to ward-based care, orwere showing signs of deterioration on a ward and wouldbenefit from input from a member of the critical care team.This lack of outreach was overcome to an extent by the unitbeing able to take less critical care patients if there wascapacity. There were plans being made to considerreintroducing this service in the future.

Are intensive/critical services caring?

Good –––

Compassion, dignity and empathyThe two patients we spoke with said the staff were kind andcaring. One patient said they felt “very safe” in the unit andsaid they had “great, really terrific care.” Two relatives of apatient said the staff had been “flexible with us and ourvisits” and “very caring.” They said they were enabled tovisit at any time and staff quickly brought them up to datewith any information if they had missed the consultantrounds. They said the consultant and anaesthetist hadtaken time and care to update them when their visitscoincided. One of the relatives said: “I can’t fault the care.The whole thing is brilliant.”

Involvement in care and decision makingThere was good involvement of patients and relatives.Patients who were able to talk to us said they felt involvedin what was happening to them. They said they were askedall the time for their consent and nothing was done beforethey were first asked if they agreed. Relatives of patientsalso said they were kept closely informed and able to makedecisions for their relative when needed, but without beingrushed or pushed in a direction they were not comfortablewith. The relatives of one patient who had been sedatedsaid their relative was fully involved with decisions takenabout their care when they came onto the unit the previousweek prior to sedation.

Decisions were taken in the best interest of patients. Anypatients who were not able to speak for themselves, or taketheir own decisions would be treated in their best interests.Staff said decisions for patients would be taken together bystaff and relatives or carers who spoke for the person. Thisincluded decisions around end-of-life care or thewithdrawal of treatment. Patients who had a decision notto provide resuscitation under certain circumstances hadbeen involved in that decision if they were able to be,otherwise their family were asked for their views and thesewere taken into account. Advocacy services were availableif patients admitted to critical care had no oneindependent of their care to speak for them.

Trust and communicationStaff built up trusting relationships with patients and theirrelatives. One patient said staff had been open and honestand spent time with them. They said staff did not justdiscuss care and treatment matters, but were interested inthe person as an individual. The two relatives we met saidthey found all the staff to be caring and sensitive. They saidstaff would “drop anything” to offer support and “could seewhen all you needed was a cup of tea and a bit of time tothink or someone to listen.” The relatives said staff hadtalked to them when they first arrived about infectioncontrol protocols; what they should and could bring ontothe unit; what they might see or hear; and what to beconcerned about or not if they should see the patientappear unwell. They said they were always told when theyarrived who was the nurse in charge of their relative andwho else was working on the ward that day. They said theywere always introduced to any agency or bank staff andtold generally about other patients, if there was anythingthey needed to know for the safety or them or the patient.

Emotional supportPatients and relatives were given good emotional support.Staff were aware of critical care units being areas of thehospital making patients and their visitors possibly nervousor scared. A patient we met said staff told them not to beconcerned about the machines and monitors. Theyexplained how they needed to beep and click, but this wasjust to make sure staff were alerted to any changes. Thepatient said they felt they could ask any questions at anytime. Part of the care plan for a patient includedconsidering their emotional support and that of their


Good –––


relatives. Staff said a calm environment was important forpatients. Visitors said they were encouraged to ensure thepatient had periods of rest, and this was included in all careplan documentation we saw.

Are intensive/critical services responsiveto people’s needs?(for example, to feedback?)

Good –––

Meeting people’s needsPatients said care was centred on them as individuals andrelatives agreed. Each patient in an intensive care bed(level three patients) had dedicated one-to-one nursingcare to meet their needs and monitor them at all times.Patients in high-dependency beds (level one or twopatients) had one nurse for two patients. This followednational guidelines about caring for critically ill patients.

Patient flow into and out of the department wassometimes not working well due to the availability of bedspace elsewhere in the hospital or with other providers. Theunit had above average numbers of patients whosedischarge was delayed or not at the optimum time, but thiswas not statistically significant. These were patients whowere medically fit to be discharged to a ward but no bedson wards were available. This may have meant beds werenot released in critical care and patients who needed themwere not admitted to the department. The capacity of thecritical care department was, however, not always reached,so patients were usually able to access the unit.

Privacy and dignity arrangements were acceptable. Theward was a mixed-sex ward, as are the majority of criticalcare units. There were curtains at each bay and the bedswere a reasonable distance apart to allow for space andstaff and family to be comfortable around the bed. Therewere two private rooms. There was, however, only onepatient toilet and bathroom (together) which all patientsneeded to share. Relatives said they were asked to leavethe patient area if any personal care or medical treatmentwas being provided. They said they had been asked if theywere comfortable with even minor checks being carried out(such as a pulse checked) and able to step away if they didnot want to witness anything they were not comfortablewith or the patient might not appreciate.

Some discharges were not at the optimum time. Researchinto critical care has shown (and hospital internal reportssupported this) there was a significant increase in mortalityfor patients who were discharged out of hours. The latestIntensive Care National Audit & Research Centre (ICNARC)report showed the department had performedout-of-hours discharges (those between 10pm and 7am)above the national average in the 12 months from April2012. Around 18% of patients were discharged out of hoursagainst the national average of around 8%.

The unit performed relatively well on not delaying patientdischarges and for patients needing to be readmitted.Around 27% of all discharges were delayed by more thanfour hours in the year from April 2012 (the national averagewas around 55%). This meant over 70% of patients whowere assessed as fit to be discharged from the unit (eitherto home or a ward) were able to leave within four hours ofthe decision being made. The statistic on patients beingreadmitted within 48 hours was relatively low, althoughabove the national average. This statistic was usually anindicator of patients being discharged too early. Just below2% of patients discharged from the unit came back within48 hours. This was an increase over the 2011/12 year whereno patients were readmitted within 48 hours, but was notsignificantly of concern.

Vulnerable patients and capacityPatients admitted to critical care were assessed to protecttheir rights and meet their needs. The hospital had accessto other services to support vulnerable patients. Therewere good working relationships with the social servicesteam. The discharge paperwork and procedures capturedinformation about a patient’s circumstances. Staff said theyhad recently cared for a homeless person who had alcoholdependency. Staff had ensured they had done all theycould to see the patient had been supported when they lefthospital and returned to the community. Staff also showeda good knowledge of working with patients with dementiaand a clear empathy for them and their relatives.

Staff had experience of supporting people with a learningdisability. Staff knew about the “hospital passport” whichwas a document people with a learning disability usuallybrought with them to tell health and social care providersmore about them. The document said what the person


Good –––


liked, did not like and how to treat them. Staff said thecarers for the patient were closely involved with their careand staff took advice from them to help support thepatient.

Access to servicesThere were no barriers to any patient accessing the serviceor them being supported by those who cared for them. Thecapacity of the critical care unit was not always fullyutilised, so patients were generally able to be admittedquickly onto the unit. The unit was also able to care forpatients who needed closer monitoring or a period of moreintensive care to stop their condition deteriorating. Apatient we met on the unit on one of our visits had beenadmitted for that reason and said they thought the carethey had been given was “amazing” and “it feels really likefirst class care. I am sure I’ll get better more quickly andable to get back home as soon as possible.”

Leaving hospitalPatients who were discharged from the unit hadappropriate records or information given to them orprovided to those receiving them into their care. Theinter-hospital transfer forms were comprehensive andcontained all the relevant information. There was a reportcontained within the paperwork where receiving staff couldrecord any issues on arrival. This included any missingmedicines, or if the patient became unwell during transfer.The patient details then recorded medicines beingprescribed, vital signs, ventilation needs, and what otherinformation was needed for their ongoing care. Theinter-hospital transfer checklist was used to ensure theother information to be relayed to the receiving hospitalwas provided. This included requirements for theambulance transfer (such as whether a paramedic teamwas needed, oxygen requirements, and if the transfer wasfor a bariatric patient). All equipment, conversations, andcontact names and numbers were then recorded.

Learning from experiences, concerns andcomplaintsThe senior staff learned from any complaints orexperiences to improve care. There were very fewcomplaints made to the department. Any complaints, if anyarose, were reported to the whole team each week. Actionplans were developed if there were changes that needed tobe made. The progress of changes was checked by theperson made responsible for their implementation. We saw

on our visit how there was an issue with the security ofpatient records. The senior sister considered this andaddressed the problem and reported back to us about thechanges made before we left the site that day.

Are intensive/critical services well-led?

Good –––

Vision, strategy and risksThe patient was the main focus of the unit’s vision andstrategy. Staff said the senior team were inspiring in thestandards of quality and safety they demanded. Thenursing and medical staff we saw treated patients and theirfamilies with the values of the NHS constitution, namelycompassion, dignity, respect and equality. Relatives we metagreed this was something they had experienced at alltimes for them and the patient. Staff were proud of the jobthey did and enabled and encouraged to deliver the serviceto a high standard.

Governance arrangementsThere were good arrangements for monitoring the serviceat local level. The senior nurse carried out regular androutine audits, although these were often on the same dayeach month, which meant they were anticipated and notunannounced. The results of the audits around care andpractices were good and staff were encouraged by staff tomaintain these high standards. The unit was part of a largerdirectorate in the trust. This meant good practice, learningfrom adverse events and experiences, and monitoring thequality of the service was shared among a wider group. Thedepartment was represented at directorate governancemeetings and this flowed through to the executive teamand trust board.

Leadership and cultureThere was strong local leadership of the unit. The matronand deputy matron worked across the other trust sitesproviding critical care. There was therefore shared learningand support for staff. The senior sisters we met on our twovisits had strong support and cooperation from the staffworking for them. We observed they were compassionateand led by example. In turn, they told us they receivedexcellent support and leadership from the matron anddeputy matron for the department. Where there hadrecently been an issue with a member of staff, this hadbeen dealt with professionally and responsibly. All the staff


Good –––


we met, both nursing, medical and ancillary (such as thehousekeeper) said they felt well supported by their peersand also their managers. They felt they could report anyconcerns they had with anything about the service orpractice and it would be listened to and addressed.

Patient experiences, staff involvement andengagementStaff felt involved and informed about patient safety andexperiences. The department held regular staff meetingswhere all staff could participate. The critical care assistantssaid they felt part of a team and were able to look afterpatients as part of their duties. All staff told us theyattended or were represented at handover meetings whenshifts were changing. They said patient safety was the maintheme of handover sessions.

The national benchmarking results were not reported backto all staff. One of the senior sisters said they no longerwere informed of the results from the Intensive CareNational Audit and Research Centre (ICNARC) although

they were aware the unit supplied the data to produce thisnational report. They said they felt this was a subject allstaff should be engaged with and see how they comparedagainst other similar units nationally.

Learning, improvement, innovation andsustainabilityStaff were appraised and given some opportunities forpersonal development. Appraisals were being held withstaff in accordance with guidelines and they were up todate for all available staff. Some of the opportunities forstaff to have personal development were being realised,but time available for teaching had recently been reducedamong a changed shift-pattern. Some staff said they felt, asone described it “a bit the poor relation” to the teams at thetrust’s other locations, and not given as manyopportunities due to time constraints, staff shortages, andthe need to travel. The senior sister had recently attended aleadership course and learning from this had beenbeneficial to the team.


Good –––


Safe Good –––





Information about the serviceHorton General Hospital maternity unit served the localpopulation and delivered around 1,600 babies each year.

The maternity service at Horton Hospital was aconsultant-led unit. There were six rooms on the deliverysuite, one of which had a birthing pool. There was adedicated theatre facility which was adjacent to thedelivery suite. This provided care and treatment to womenfor elective and emergency caesarean sections. On the firstfloor there was a 14-bedded ward where ante- andpost-natal care was provided. The women requiringspecialised care were transferred to the maternity unit atthe John Radcliffe Hospital in Oxford.

As part of our inspection we sought the views of peopleusing the service. We spoke with nine patients, six relativesand 14 staff. These included a multidisciplinary team suchas doctors, midwives, consultants, midwife supportworkers and allied health professionals. We observed careand treatment to assess if patients had positive outcomesand looked at the care and treatment records. We gatheredfurther information from data we requested and receivedfrom the trust. We undertook interviews, ran focus groups,listening events where staff and members of the publicwere consulted. We looked at comments cards, surveysand the process for the management of complaints by thetrust. We used all the information to plan and inform ourinspection.

Summary of findingsThe maternity unit provided safe care which wastailored to the needs of women receiving pre- andpost-natal care.

Women received care from caring, compassionate andskilled staff. We received positive comments fromwomen and their families about the care and supportthey received. They were involved in decisions abouttheir care and received emotional support as required.

The unit was clean and staff followed the internalprocedures for hand washing. Hand gels were availableat different points and visitors were encouraged to usethem. Staff had completed training in infection controlto ensure women and babies were protected from therisk and spread of infection.

There were systems in place to record near misses andother events and the staff were aware of theirresponsibility to record and report these incidents.There was evidence that learning from incidentsoccurred and action plan developed.

People were safeguarded from the risk of abuse. Staffhad received training in safeguarding and were aware ofthe process to report any such issue. This ensuredpatients were not put at risk, as appropriate safeguardswere in place.

Most practice was in line with national guidelines. Therewere concerns about the lack of support for newly

Maternity and family planning

Good –––


qualified midwives which may impact on care delivery.The labour delivery suite had been without a managerfor 18 months although attempts had been made torecruit to the role.

The service was well-led. There were clinical governancestrategies and regular meetings which looked atdevelopment of the service. Staff felt supported withinthe ward and units; however, they told us they feltdisconnected from the wider organisation.

Are maternity and family planningservices safe?

Good –––

Safe and PerformanceWomen and babies were protected from the risk of abuseas appropriate arrangements were in place. Assessmentswere undertaken in the community and information aboutpatients who were at risk was shared with the staff at theunit. A coding system was used to ensure this informationwas not missed and women continued to be safeguardedon admission. Staff had completed training in safeguardingadults and children and had access to the policy onsafeguarding. Staff were aware of the signs of abuse andaction they were aware of their responsibilities in reporting.

Learning and improvementThe hospital had systems in place to learn from incidents.Following an incident where a patient developing apressure ulcer following epidural, there was an action plandeveloped to minimise the risk of recurrence. This wascascaded to the staff on the “topic of the month” board.This included information about the observations andrecords to be completed and lesson learnt from theincident. Also, written information about safe sleepingarrangements for babies was made available to parents,following an incident. This was available on maternitywards.

Systems, processes and practicesThere was a system in place for monitoring severely illwomen, both during pregnancy and immediatelypost-delivery. This process was well-established and theyused the Modified Early Obstetric Warning Scoring system(MEOWS). Information from the Clinical Negligence Schemefor Trusts (CNST) report from November 2013 across thetrust showed these were not always consistentlycompleted and may impact on the level of care. Action hadbeen taken and these were complete in the records seen.This meant women were monitored and any changes intheir health were identified promptly for action as needed.

Arrangements were in place for patients to be transferred toother hospitals depending on their condition. This ensuredthey received the correct treatment in a timely way andaccording to their needs.


Good –––


There were policies and procedures in place regarding theMental Capacity Act 2005. Staff were knowledgeable aboutthese processes. All staff had received training insafeguarding adults and children.

Infection controlThe maternity unit wards looked clean and the cleaning ofthe unit was shared between the midwifery supportworkers and domestic staff. They were all clear about theirareas of responsibilities. We observed staff and patientsconfirmed the staff followed the hand washing proceduresand the use of hand gels as appropriate. Hand-washingfacilities were available in different parts of the unit andaccessible. Information about the use of hand gels wasdisplayed and visitors confirmed they were prompted touse hand gel on entering and leaving the wards. Personalprotective equipment such as gloves and aprons wereavailable and we observed these were used as appropriate.We noted equipment was cleaned in between each patient.A recent hand-washing audit showed the unit had scored96% and achieved compliance. This meant the stafffollowed their procedure ensuring good infection controlmeasures were in place. Infection control practices werepromoted to reduce the risk of cross infection.

The monthly inspection control audit for hand washing wascompleted and results were displayed to inform staff andvisitors to the unit. There was a system for the frequency ofre-auditing depending on the score achieved and thiscould be as soon as one week. There was clear informationfor the staff about infection control. This meant infectioncontrol was taken seriously and action taken to protectwomen and their babies.

Management of emergenciesArrangements were in place for the management ofmedical emergencies. On each unit there was anemergency trolley appropriate to deal with babies andadult emergencies including resuscitation. The equipmentand the emergency drugs were in place and daily checkswere completed. A record of the checks was maintained toensure the emergency equipment was fit for purpose. Staffreceived training in resuscitation (including neonatalresuscitation) and this was updated on a yearly basis.

Pain controlWomen received medication and appropriate pain relief asprescribed and in line with policies and procedures. Theysaid they had received adequate information about paincontrol during labour, including information about

epidurals. The anaesthetist discussed pain control onadmission to the hospital. For women having electivecaesarean sections this was discussed during outpatientappointments.

Post-operative pain control was prescribed for women whohad caesarean sections and there were systems in place toenable self-medication.

We looked at the arrangements for patients who requiredsurgery on the maternity unit. The hospital used the WorldHealth Organization (WHO) surgical safety checklist inoperating theatres. This is a system which followed threesteps in order to minimise the most common andavoidable risks for surgical patients. Records reviewedcontained completed WHO checklists which demonstratedcompliance with the use of this.

Monitoring safety and responding to riskThe hospital was proactive in identifying risk and ensuringpatients were in the most appropriate place for their careand treatment. Women who were assessed as at high riskwere transferred to the hospital in Oxford. The trust hadtaken the decision for diabetic patients not to be treated inthe maternity unit at the Horton because there was not anurse specialist.

Decisions about care and treatment were taken at theappropriate level. A lead coordinator on each ward wasavailable to coordinate the overall management of theunit. This also supported other midwives and enabledpractice to be monitored.

Staff confirmed they had adequate staff with the right skillsto provide care and support to the women and babies.They had a system of internal support and continuousreviews were completed to ensure the staffing levels weresafe. All women in the labour suite had one-to-one care.We observed a patient who was admitted in theobservation suite and found they received one to onesupport. The midwives used a “fresh eye” process wherewomen who were at risk were monitored. A second opinionfrom another midwife was sought to ensure the careremained appropriate. The staff moved between the twowards depending on the skills required and the women'sneeds. Staff reported this worked well and this meantwomen received the care and support to meet their needs.


Good –––


Information from the trust indicated they had experienceddifficulty in recruiting to medical posts in maternity.Medical cover was by locum doctors in the delivery suite,maternity ward. There was 24-hour consultant cover inplace for the maternity unit, including theatres.

Maternity staffing across the trust was reviewed annually. Amaternity staffing paper to the trust board in May 2013stated that the midwife to birth ratio was 1:32-1:33 whichwas outside the national guidance (Safer ChildbirthOctober 2007) which was a ratio of 1:28. This resulted inmidwives being moved from clinical areas into the deliverysuites to ensure that there was adequate staffing to ensuresafe births. The paper stated “having considered thenational guidance, the financial implications and the needto provide a safer service, the Head of Midwifery believedthe service could currently be provided safely with a ratio of1:30. However, if the activity and acuity should significantlyincrease beyond current levels, there would be a need torevisit the staffing requirements.” Data from January 2014showed the hospital was achieving a midwife to birth ratioof 1:31. At the hospital senior staff had identified issues inensuring midwifery cover in theatre areas, althoughmidwife support workers were being developed to supportin this role.

Anticipation and planningThere were plans in place to ensure that there wereadequate numbers of staff in place through thedevelopment of midwife support workers. The hospitalused Birth Rate Plus for assessing and managing themidwifery workforce levels. This is a recognised tooldeveloped for the maternity services to assess the staffinglevel needed. This informed the number of midwivesrequired based on clinical needs and risk. Midwiferystaffing levels were reviewed across the trust prior to ourinspection. Although Birth Rate Plus does not support thereplacement of midwifery time with midwife supportworker time during the antenatal and birth pathway, aninitiative to develop midwife support workers to provideadded assistance including in theatre had beenimplemented. This was in conjunction with Oxford BrooksUniversity.

Information from the trust identified concerns with the lackof out-of-hours anaesthetic cover because the anaestheticnurse on call could take up to 20 minutes to arrive. Thiscaused delays in emergency caesarean sections. The trust

had taken action and reports in October 2013 identifiedthat recruitment for onsite anaesthetic cover wasunderway. Some posts had been filled and recruitmentcontinued.

Are maternity and family planningservices effective?(for example, treatment is effective)

Good –––

Evidence-based guidanceThere were policies and procedures in place on the trustintranet which staff confirmed they were able to access.The maternity services training policy was available to allstaff at induction. There were also clear procedures andguidelines were adhered to in relation to the termination ofpregnancy.

On the maternity unit the “immediate care of the new-bornguidelines” has been updated to reflect NICE guidance. Thetrust had introduced the New-born Early Warning Scorechart (NEWS). The NEWS observation chart was used toidentify any deterioration in a baby’s condition andreported to the midwife caring for the baby. This meantaction could be taken at an early stage and appropriateintervention put in place.

There was a variety of information based on research andNICE guidance which were available to inform mothers.These included choosing induction or waiting for labourafter rupture of membrane, caesarean sections and lowmolecular weight heparin (LMWH) for the prevention of clotformation.

At times National Institute for Health and Care Excellence(NICE) guidelines were not followed when considering theuse of ventouse cups or forceps to enable delivery. Trustdata showed a higher rate of forceps delivery thanexpected. Staff said this was due to a particular type ofventouse device being withdrawn from use and staff hadreverted to using the means of forceps delivery.


Good –––


Performance Monitoring and improvement ofoutcomesA range of audits were carried out both locally andnationally. The outcome of these audits were discussed atregular meetings and action plans developed in order toimprove practices.

The trust had lower rates of both emergency and electivecaesarean sections when compared with other trusts inEngland. Similarly, the trust had a lower ventouse deliveryrate, but a higher forceps cephalic delivery rate.

Data was collected about the effectiveness of epidural andspinal pain relief, where patients’ views were sought. Thislooked at the effectiveness of pain control in order toensure care and treatment was planned according toneeds.

There was evidence that learning from incidents wasmonitored. Information from the trust papers showedchanges in practice were implemented for perineal care.This had resulted in the reduction in third and fourthdegree tears for women in their care.

Staff, equipment and facilitiesThere was no designated antenatal ward at the hospitaland the arrangement was for the antenatal patients to beaccommodated in the same bay if possible. Theenvironment was clean and safe with a programme ofrefurbishment. A senior member of staff confirmed theyhad adequate monitoring equipment available. Theseincluded fetal heart monitoring machines. We observed theequipment in the labour unit was clean and staff told usthere was a system for servicing the equipment althoughthey did not have any records on the wards as these wereheld centrally.

There were systems in place for monitoring thetemperature at which medicines were stored, including themonitoring of fridge temperatures. Medicines were securedappropriately in most areas. However, there was nolockable storage for medicines within the anaesthetic roomin the maternity theatres. This was identified six weeksprior to our inspection and requests were made to addressthis but were still outstanding.

Multidisciplinary working and supportThere was good multidisciplinary working across thehospital and community maternity services and withinother services in the hospital. Staff felt supported by

specialist midwives responsible for bereavement, breastfeeding and also by allied healthcare professionals. Wenoted there was a supportive and open culture and stafffelt well supported by the consultants.

Are maternity and family planningservices caring?

Good –––

Compassion, dignity and empathyWomen and their family were positive about the care andtreatment they had received. They commented the staffwere knowledgeable and compassionate. Some of thecomments included: “since I have come here everythinghas been excellent”. We were told the staff were welcomingand addressed them by their name. A patient said theyarrived at the unit that morning and staff were "ready andwaiting" for them. They felt reassured by the support theywere provided.

We observed women’s privacy and dignity beingmaintained within the maternity unit.

Involvement in care and Decision MakingWomen were informed and involved in decisions abouttheir care. Records showed women were involved inmaking decisions about their care and consent was sought.Women and their partners were involved in their carethrough ongoing consultation. This started at the antenatalstage and continued throughout their ante and postnatalcare, including decisions about tests for fetalabnormalities, and the options available were fullydiscussed.

There was inclusive discussion between midwives, doctors,women and their partners about treatment. This includeddiscussing the pros and cons of treatment and theprovision of verbal and written information to assistwomen to make informed choices and decisions. Womenalso told us they were fully informed and consulted aboutthe birth plan including plans about elective andemergency caesarean sections. Women were well informedabout the possibility the birth plan may not be followed ifthey required emergency intervention.

Trust and respectCommunication between the midwives, women and theirfamilies was good. Women and their partners were


Good –––


supported and able to ask questions. Women said themidwives were very good at listening and providedsupport. One woman said they were aware that eventhough they had a birth plan, this may not go to plan andthey were prepared for this. They felt they had confidencein staff and trust and communication was good. Weobserved advice given over the phone to women andpartners queries, were clear and provided reassurance.

Staff and patients described their experience of care aspositive and were complimentary about the care andsupport they received. Staff said they worked very well as ateam as this was a small area and they rotated between thelabour ward, and post and antenatal work.

There was a variety of information and leaflets appropriateto the maternity unit. There was also a breast feeding caféwhich had been well received by new parents. Advice andguidance was provided on family planning to women onthe postnatal ward and followed up by midwives during thepostnatal visits in the community.

Emotional supportWomen and their partners were positive about theemotional support they received from midwives andsupport staff. One woman said: “I was totally drained andthe staff were very understanding. I received great supportwith breast feeding”.

Arrangements were in place to provide emotional supportto patients and their family in a sensitive manner. Therewas a bereavement specialist midwife and pastoral careservice was available to support women, partners and theirfamilies if they chose. There was a fully-furnishedbereavement suite with separate access with en-suitefacility and a small kitchenette. This ensured women, theirpartners and their children had the opportunity to haveprivate time. The suite contained a single bed and may notbe appropriate for partners and children to stay overnight.

Advice and support for antenatal complications andtermination of pregnancy was managed sensitively andstaff told us a counselling service was available to patients.

Are maternity and family planningservices responsive to people’s needs?(for example, to feedback?)

Good –––

Meeting people’s needsThe needs of the women were assessed and care birthplans were developed to meet those needs. There was anobservation ward in the labour suite where women wereadmitted for close observation. Women were admitted onthe wards where antenatal care was provided. Women saidthe service was very good and they had receivedappropriate care and support.

Specialist midwives were employed to provide support forthe patients and staff. These included staff with leads rolesin diabetes management in pregnancy, breast feeding,physiotherapy and exercise. Post natal advice and supportwas available to assist mothers with incontinence andbowel problems.

Translation services were available. Information andcontact details were provided for patients who needed aninterpreter. Information was also available in other formatssuch as braille, large print, an audio version, and inlanguages other than English.

Staff said delays in getting a translator had impacted onwomen’s care particularly regarding pain management. Aprocess was in place to ensure that information regardingthe need for a translator to be gathered and recordedduring antenatal care. This was to ensure arrangements forbooking this service were initiated earlier.

Care plans were detailed and contained informationincluding: fetal and maternal wellbeing, diet, hydration,pain control and mobility. All women had a venousthromboembolism (VTE) assessment to assess their risk forblood clots. Treatment plans were in place. A patientcommented the staff had encouraged them to have regularpain control. They felt this had helped in their recoveryfollowing a caesarean section.

Access to servicesInformation indicated arrangements were adequate andthere were no issues with access to care. Staff, women andtheir partners, confirmed this. Patients told us they felt theservice was good and served the local community well.


Good –––


Vulnerable patients and capacityPatients who were at risk of domestic violence weresupported and advice was available to them. Staff followedthe care pathway for patients with mental health problemsand were able to access support from externalprofessionals to help and support these patients.

There were neonatal abstinence procedures for treatmentfor babies born to mothers who had used drugs. Therewere clear guidance on the monitoring process for thesebabies and their management.

Leaving hospitalThere were discharge arrangements in place for womenand babies. Discharge information was faxed to women’sGPs and the community midwives. At weekends stafftelephoned the community teams to ensure they wereaware of patients who had been discharged. Patients werealso advised to ring the maternity unit if they did notreceive a visit from their midwives within a specifictimeframe following discharge.

The maternity unit had a procedure for take homemedicines to be dispensed from the unit. This was aneffective way of discharging patients without having to waitfor medicines to be dispatched from the hospitalpharmacy.

Learning from experiences, concerns andcomplaintsThere were clear policies and procedures available towomen and their partners about how to raise theirconcern. We saw leaflets were also available in differentareas of the wards and labour unit. Patients could alsocontact the Patient Advice and Liaison Service (PALS) if theyneeded support about raising concerns.

We received positive feedback about the care andtreatment patients were receiving. Those we spoke withwere aware of the procedure to raise a concern. Staff toldus they would speak with their immediate mangers if theyhad a complaint or concern, but, said they would not raiseconcerns at trust level.

Are maternity and family planningservices well-led?

Good –––

Vision, strategy and risksThe trust achieved Clinical Negligence Scheme for Trusts(CNST) Maternity Level 2 in November 2013. The qualityand audit paper from 2013 showed the trust was workingwith the University of Oxford and its partners in thecommunity (including GPs and the Community PartnershipNetwork) to formulate proposals to maintain a full obstetricservice at the Horton. The proposed model involved jointclinical and research posts to support the obstetric roster.Staff and patients were passionate about keeping the localfacility and had full support from the local community. Thetrust board members had engaged with the localcommunity about the transfer of some services to Oxford.

GovernanceGovernance arrangements ensured that responsibilitieswere clear. Quality and performance were regularlyreviewed and any concerns or problems identified werediscussed and strategies developed to address them. Therewas a system of learning from incidents. There wereongoing audits including the “maternity dashboard”. Thiswas a system of monitoring and reporting on the quality,safety and key performance indicators within the maternityunit. This formed part of their monthly risk strategy meetingwhere this was discussed and action plan developed.

A trust paper from January 2014 about the learning fromcomplaints showed they were reviewed on a quarterlybasis. Recurring themes were identified and action plansdeveloped to manage the root causes.

Leadership and cultureThe staff said there were good working relationshipsbetween the medical staff, midwives and otherprofessionals. Staff felt supported in their roles and werecomfortable to raise their concerns at local level. Seniormanagement and other staff we spoke with were clearabout the trust vision and values. Staff told us they weresatisfied with the local management arrangements, butthey felt disconnected from the organisation and trustboard. They said this was due to communication.


Good –––


Patient experiences and staff involvement andengagementStaff were positive about working in the maternity unit andsaid they were proud to be working there. They said therewas excellent team working and felt well supported bycolleagues and their immediate managers.

Women said they found the staff at the maternity unit verygood or excellent. They felt the staff engaged with themand provided care and support according to their needs.

The staff felt the lack of senior management on site overthe two years prior to our inspection had caused them tofeel neglected by the trust. They felt bed closures andtransfer of care to Oxford were due to financial reasons andnot with patient care in mind. The staff felt there was nooverall cooperation or coordination on site because mostsenior staff were based in Oxford. The managementstructure had also impacted on communication with theJohn Radcliffe Hospital. Staff said morale on site was poorand felt they could not openly discuss their concerns.

Learning, improvement, innovation andsustainabilitySenior managers told us they had a successful recruitmentdrive for midwives and that this needed to continue.

The staff on the maternity unit were supported in theirroles. They had a lead midwife on each shift who providedadvice and support for the staff. The electronic patientrecord (EPR) was not fully utilised and some records werein paper form. We were told this was being addressed andwould be reinstated.

The quality and risk audit highlighted the current problemwith providing “tongue tie” service for babies. This wascurrently provided by the paediatric service with aprolonged waiting time which impacted on the babies. Thetrust was looking at strategy of training midwives to carryout this service as an extended role.


Good –––


Safe Good –––





Information about the serviceThe directorate provided acute and outpatient generalpaediatric services at the Horton General Hospital inBanbury and the John Radcliffe Hospital site in Oxford

The service included the assessment and management ofacutely unwell children, inpatient treatment and intervalreview of children referred by their GP or presenting to theemergency department and an outpatient service for localchildren requiring secondary level paediatric care.

The service included a consultant led children’s ward with17 beds for patients, the special care baby unit had spacefor 10 beds and there was a small outpatient service.

Facilities included a large playroom with educationalfacilities and family rooms for parents/ guardians to stay inthe hospital.

We visited the children’s ward on a Tuesday during thedaytime and again on a Sunday afternoon and earlyevening as an unannounced visit. During these visits wetalked with around nine patients and their relativesaccompanying them. We spoke with staff, including nurses,doctors, consultants and support staff. We also receivedinformation from people who attended our listening eventsand from people who contacted us to tell us about theirexperiences. We collected comment cards from adesignated box set up for our visit. Before our inspectionwe reviewed performance information from, and about thetrust.

Summary of findingsThere was a multidisciplinary collaborative approach tothe care and treatment of children across children'sservices in the hospital. Children's care and treatmentwas planned and well documented in the medical notesand nursing records in the patient's files. Staff acrosschildren’s services were confident the hospital had areliable system to alert them to risk and implementimprovements. Staff told us they could express theirviews in ward meetings and were “confident” theywould be listened to by the organisation.

Children and young people received person centredcompassionate care from staff in the children’s ward. Wesaw nursing staff delivered kind and compassionatecare to a young child who was crying as their motherhad gone home. Parents told us nursing staff had been“patient and kind.” Care delivered was safe andeffective.

Services for children & young people

Good –––


Are children’s care services safe?

Good –––

Safety and performanceStaff across children’s services were confident the hospitalhad a system to alert them to risk and implementimprovements. All staff used the same incident reportingsystem to ensure consistency. They told us it was “a reliablesystem” to address the concerns they had raised. One staffmember described the reporting system as a “good” and“easy to use” and spoke positively about “quick response toconcerns” by the hospital.

All staff spoken with were well aware of theirresponsibilities in relation to ensuring the safety ofchildren. All paediatric nursing and medical staff includingconsultants had completed level three children'ssafeguarding training.

Learning and improvementThere was evidence of learning and improvement as aresult of incidents and concerns raised by staff. Forexample, staff members in SCBU raised an incident on thesystem about the impact of the safe care for babies due tolack of access to an Ophthalmologist. They were concernedabout babies receiving timely eye tests. A senior staffmember said: “in two just weeks after the report anOphthalmologist was in place.”

The risk register, completed by senior staff, raised concernsabout the administration of some medicines and the safetyof the lift to the unit. Staff told us these had been resolvedin a timely manner.

Systems, processes and practicesThere were sufficient systems and practices in place toensure children were safe in the hospital. In the children'sward there were daily nurse and consultant-led handovermeetings to discuss the care and treatment of patients. Weobserved the hand over meeting was led by the consultanton the previous nightshift who handed over to the day staff.The handover included two consultants, a locum doctorand a GP trainee. The handover included details of thechild, the diagnosis, investigations, the management of theconcern and the treatment plan. In SCBU the handoverincluded, in addition, the babies feeding plan and thegestation weight. There were details of any concerns about

children discussed at the monthly perinatal meeting andthe Friday morning paediatric meeting which included any“child protection forum cases.” A consultant-led wardround immediately followed the handover and theseincluded nursing staff to ensure information was sharedand continuity of care for the children. A consultant said:“They ensure information about children is circulatedeffectively.”

EquipmentNursing staff told us they had access to equipment from theequipment library in the John Radcliffe Hospital in Oxford.They had reviewed their equipment and identified thecurrent bathrooms could not fit a hoist to assist with thesafe transfer of children as there was not enough space. Anurse said: “It is difficult as we can’t bath children whocannot mobilise themselves." They told us the hospital hada plan to refurbish the bathrooms.

Infection controlThe hospital provided safe care and treatment for childrenin a clean environment. Staff across children’s servicesfollowed infection control procedures. In the Special CareBaby Unit (SCBU) infection control policies and procedureswere displayed on a central notice board in the special carebaby unit to ensure they were easily accessible to staff,parents and visitors. There were monthly infection controlaudits and results were discussed in ward meetings andthen actioned by the staff team. For example, the staff teamidentified the clutter on the bed-side tables as a site forpotential cross infection. This was because babies’dummies were too close to the bowls used for washingwhen changing nappies. They introduced clean and dirtyareas to separate possible areas of cross infection. A seniorstaff member said they also completed “surprise audits” toensure ongoing compliance and to "keep everyone on theirtoes.”

Space in the SCBU was limited. As a consequence therewas limited space between the babies’ incubators and cotscreating potential possible sites for cross infection. A seniorstaff member addressed this by moving the cots when notin use. They said: “it’s sometimes not ideal and storage hereis always a problem but we utilise the space we have anduse it in the best possible way.” A parent in SCBU said: “Ifeel like my baby is in safe hands here.”

In SCBU staff followed infection control procedures inrelation to wearing personal protective equipment likegloves and aprons. Staff were observed washing their own


Good –––


hands and reminding patients and visitors. The handwashing area was in the middle of the unit staff ensuredvisitors used this area appropriately. A senior staff membersaid: “I have put the signing-in book by sink to encourageand remind people to wash their hands and it works well.”

The children’s ward was clean and tidy in all areas. Toiletswere hygienic and staff were aware of the infection controlprocedures. Information was available for them in the staffmeeting minutes, the infection control policies andprocedures were accessible in the staff area and there wasonline guidance with email reminders for staff to attendmandatory training. A staff member on the children’s wardsaid: “We know systems for following Infection control, wehave cleaning schedules and equipment is tagged anddated after cleaning with ‘I am clean’ stickers.” Theplayroom was cleaned by the play specialist. The toys andequipment were well maintained, clean and hygienic. Toysplayed with by contagious children were cleaned beforereturning to the play area.

Care PlanningChildren's care and treatment was planned and welldocumented in the medical notes and nursing records inthe patient's paper files. We reviewed five patient's files inthe children’s outpatients department. In two files it wasrecorded children did not attend their outpatientappointment. On both occasions the consultant followedescalation protocols and wrote to alert the child'scommunity doctor. The medical information in thetreatment plans was well structured with detailed clinicalnotes, details of examinations and investigations, andwritten evidence of conversations with parents andchildren about the treatment plan. In three of the five filesthere was a record of patient’s examination findings toinform future treatment.

Monitoring safety and responding to riskThere was an effective paediatric early warning scoresystem in use to try and ensure the early detection of anydeterioration in a child’s condition. This system was knownto all staff spoken with. It ensured the early escalation ofpossible changes to a child's care needs to ensure theyreceived safe and effective care in a timely manner Therewas a ”flag” in the electronic patient records used toidentify any patient of concern including childrensafeguarding concerns.

If children's safeguarding concerns were confirmed thesewere escalated to the incident reporting system. Paediatric

consultants from the children’s ward provided an on- callservice to the accident and emergency departmentincluding out of hours cover. Staff in the emergencydepartment described the cover as “easily accessible and“very supportive.” A paediatric consultant in the children’sward told us they also worked closely with the Child andAdolescent Mental Health Services (CAMHS) for concernslike deliberate self-harm in adolescents.

In the children's ward a senior nurse was the safeguardinglead. There were close links with safeguarding link nurses inthe John Radcliffe Hospital and “link” workers in socialservices, health visitors and school nurses in thecommunity. Safeguarding concerns were also discussed atthe monthly paediatric consultant meetings andmultidisciplinary meetings. A senior nurse said: “We have awell-run service where everyone understands their role insafeguarding. It works well.”

Staffing levelsThe children's ward was a consultant-led ward with nursingstaff and a clinical support worker. There was theconsultant of the week and an additional consultant tocover the ward. There was a system of some sharedpaediatric consultant cover (hybrid) between the hospitaland the John Radcliffe Hospital in Oxford. There were eightconsultants and four hybrid posts which includedout-of-hours cover. This meant there was full day-and-nightconsultant cover for the unit. A consultant told us cover is:“good but complicated. In effect there are two parallelservices with the John Radcliffe hospital.” Anotherconsultant told us: “The second on-call consultant is usefulif a child presents in the emergency department with childprotection concerns. A paediatric consultant can completea timely assessment as the child will mostly come to thechildren's ward.” They said “the second consultant coversthe rest of the ward so It works well.”

In SCBU a senior staff member told us they were rarelyshort staffed. The duty rota showed there were sufficientnurses in the day and evening to care for the babies safely.A senior staff member said: “We have nursery nurses whowork during the day to teach the parents parenting skills.There are also two paediatric consultants and a seniorhouse officer all the time.” One nurse told us: “We arewell-staffed so we are not rushing around all the time.”

Anticipation and planningStaff worked closely with other agencies to ensure therewas a clear plan for children’s safe discharge in to the


Good –––


community or transfer to other hospitals. Young peoplewith mental health concerns were not discharged from thechildren's ward until a full CAMHS assessment had beencompleted to confirm it was safe to discharge them. Apaediatric consultant told us the CAHMS service was localto the hospital so young people “benefited from timelyassessments.”

Records reviewed in both the children’s ward and SCBUshowed there were clear co-ordinated plans for children’sdischarge. Records included liaison with social services,health visitors, school nurses and the CAHMS service toensure consistent working. Parents were clear about thearrangements for outpatient appointments for childrenand told us they were given sufficient information. Parentsin SCBU confirmed they were involved in the plan fordischarge and described it as well planned.

Are children’s care services effective?(for example, treatment is effective)

Good –––

Using evidence based guidanceChildren received care and treatment in line with currentlegislation and national guidelines. Staff were aware howto access these on the trust’s intranet. For example, asenior staff member in the children's ward told us theyfollowed the trust’s guidelines in line with the NationalInstitute for Health and Care Excellence (NICE) guidelinesabout sedation of children under six years to ensurechildren were treated safely. The hospital monitored andaudited their care and treatment of children in relation tothis guidance and there were action plans to address anyarea of concerns to improve practice.

Other guidance and audits included Aseptic Non TouchTechnique (ANNT) about the preparation and delivery ofintravenous medication. A nursing staff member told us:“We make sure key parts, like the tip of the syringe, areclean.” They told us additional training was put in place ifthe guidelines were not met. Staff also told us theyfollowed trust guidelines, pathways, protocols and policiesin relation to the “limping child” pathway. Staff accessedguidance via the trust-wide intranet under acute paediatricproblems within children’s services. The guidance included

investigations, diagnosis and possible referral to thepaediatric orthopaedic team. A nurse told us: “It’s very easyto use the intranet and it means we have instant access tothe guidance.”

Staff told us they followed the hospital’s pain managementprocedures and used a pain-scoring tool to assess childrento ensure children had sufficient pain relief. These scoreswere available in the treatment files reviewed. A nurse toldus: “We all use the same format so it’s very clear.” A parentin the children’s ward told us the nursing staff had: “madesure my child was not in any pain when we arrived at theward.” A senior nurse in the Special Care Baby Unit (SCBU)told us: “We use dummies to assist pain in very smallbabies.” An audit was currently taking place for pain relief inneonatal babies to improve and develop practice.

All staff in the hospital followed guidance called the “fluidchallenge” to ensure children were sufficiently hydrated. Anurse in the children’s ward told us: “It is important weensure children have sufficient drinks as it assists in theirrecovery.” Treatment plans included an assessment ofchildren’s hydration.

Performance, monitoring and improvement ofoutcomesStaff monitored outcomes for children to ensure theyreceived safe effective care. Staff members told us theywere involved in a variety of audits to monitor and improvecare for children. All staff spoken with were able todemonstrate knowledge of the “electronic patient flag” tohighlight concerns about children and the “escalationstream” to protect them.

In SCBU a senior staff member told us they had regularbenchmarking for consistent outcomes for children withother trusts, to compare and develop their practice. Asenior nurse said: “A staff member goes into other hospitaland compares what we are both doing about, for example,the positioning of babies and then we discuss thesimilarities and difference at ward meetings.”

Staff, equipment and facilitiesChildren benefited from well-maintained and hygienicequipment and child-centred facilities in the children'sward.

In the children’s ward there was a large play area openweekdays and occasional weekends. A teacher wasavailable three days a week to provide education for olderchildren and a play specialist to work across children’s


Good –––


ages. The play specialist told us: “My role is to offer playsessions to enhance children’s experience and distractthem when they were having procedures like blood tests.”We saw there was a range of age appropriate books,puzzles and toys and sensory toys with lights for childrenwith sight impairments.

Nursing and medical staff across children’s services at thehospital confirmed they received annual appraisals whichincluded feedback about their performance. The electronicrecording system assisted with appraisals as senior staffwere alerted to staff appraisals due. Nursing staff spokepositively about the appraisals as monitoring performance.One nurse said: “The new appraisals mean you can easilysee what is written and sign to indicate you agree with thecontent.”

Multidisciplinary workingThere was a multidisciplinary collaborative approach to thecare and treatment of children across children's services inthe hospital. Staff in the emergency department spokepositively of the consultant support they received from thechildren's ward. A consultant in the children's ward said:“Close links to Oxford means we have easily accessiblespecialist advice if required.”

There was multidisciplinary working to safeguard childrenin the hospital and in the community as data from theescalation process was linked to the paediatric liaisonhealth visitor in the community, link social workers andschool nurses. This meant there was a consistent systemfor sharing information.

Are children’s care services caring?

Good –––

Compassion, dignity and empathyChildren and young people received person centredcompassionate care from staff in the children’s ward. Wesaw nursing staff delivered kind and compassionate care toa young child who was crying as their mother had gonehome. Parents told us nursing staff had been “patient andkind.” One young person told us they liked the staff.

Involvement in care and decision makingParents told us they were consulted in all aspects of thecare and treatment of their children. One parent in SCBUsaid “staff here are great. They have kept me informed

every step of the way. I feel very involved which is reallyimportant to me with a new baby.” We observed staff talkedto one parent about how their baby had fed during thenight and agreed a feeding plan with them for the dayahead. This showed involvement of the parent in ensuingtheir baby’s needs were met.

Nursing staff told us talking with parents was central totheir work. We read ten patients records in children'soutpatients, SCBU and the children's ward. There wererecorded discussions between parents, the child, nursingstaff and paediatric consultants about the content of thecare and treatment plan in each file. Parents for whomEnglish was not their first language told us staff had beenclear and used “language we can understand” to ensurethey knew the contents of their child’s treatment plan.

Trust and communicationPatients and their carers valued their relationships withstaff. One parent in SCBU told us “I feel I can ask themanything. Once I wanted to see my baby really late at nightas I was a bit anxious and they let me into the unit. Myhusband couldn't sleep one night because he was worriedabout our baby so he rang up the staff here. They talked tohim for ages. They understand how concerned we get andhelp us to get through it.” Another parent said they trustedthe staff in SCBU as they knew their baby was “in safehands.”

Emotional supportParents told us they were supported by nursing staff in thechildren's ward. One parent in the children’s ward told us“they helped me as much as my child when I was upset.”Nursing staff told us about the dual role of treating childrenand supporting anxious parents. A senior staff member inSCBU said “it can be a very anxious time for parents so weoffer them comfort, care, food, drink and a bed here, sothey can stay with their children.” One parent said: “Theparent’s room is basic but I'm so glad it's there so I can benear my baby.” In the children's emergency department aparent said the consultant they saw was: “Willing to takethe time to listen to me.”

Are children’s care services responsive topeople’s needs?(for example, to feedback?)


Good –––


Good –––

Meeting people’s needsThe hospital planned its children’s services to meet theneeds of children in the local community. The hospital haddeveloped children's outpatient service to meet theincreased demand in the community. A senior staffmember from the outpatient department told us: “We havereviewed our children's outpatient service as what wecurrently have just isn't sufficient. On clinic days (weekdaymornings and Thursday afternoon) we only have space fortwo chairs for patients in the small waiting area. We bringout a box of toys and put them next to the chairs in an areathat is only a couple of square metres. We know it is nothygienic having children playing on a carpeted area, but itwas the best we could do. We don't have any paediatricnurses. We tried using paediatric trained nurses from thechildren's ward but it didn't work out.”

In December 2013 children's outpatient provision wasidentified as a concern on the hospitals risk register and itwas discussed at the monthly multidisciplinary children'sdivision (CDU) meeting. A senior staff member said: “Weworked closely with the Director of Operations. Weidentified a self-contained area close to our current siteand made it into a separate unit for outpatients forchildren.” The date for completion on the risk register wasDecember 2014. The unit was, however, almost completeapart from some refurbishment. A staff member said theexpected operable date was “in the next couple of months.”The manager told us the unit would include paediatrictrained nurses, paediatric consultants, a play specialist,dedicated treatment rooms and a play area. Access to thearea was via a lockable entrance making it secure forchildren. A senior staff member told us: “this newdevelopment will mean we can offer a dedicated andseparate outpatient service for children.”

Access to servicesA staff member in the children's ward told us they workedclosely with children's services in the John RadcliffeChildren's Hospital (JR) providing a joined-up responsiveservice to the needs of children in the community. Thechildren's ward provided additional children’s beds when

children’s hospital was full. Parents told us how they valuedhaving a local children's ward. Some children had openaccess to the children’s ward if they were known to theward with for example a chronic condition.

Staff told us patients have timely access to the translationservice which was “not on site so we book it in advance.”They told us they had regular and easy access to aninterpreter and sign language interpreter for parents withhearing impairments. A member of staff said: “We use it allthe time.”

Vulnerable patients and capacityStaff ensured the needs of vulnerable young people weremet. Staff liaised closely with the Child and AdolescentMental Health Service (CAMHS) which is part of OxfordHealth NHS Foundation Trust. This was to ensure the needsof children and young people who experienced mentalhealth problems and needed access to specialist mentalhealth services after discharge were accommodated. Therewas positive written feedback from young people abouttheir time on the ward which stated: “staff listened to what Iwanted.”

A senior nurse told us “we see a lot of young people witheating disorders so we can access training and guidancefrom the Trust in this area.” Staff told us they could accesstraining and guidance about care pathways and needs ofvulnerable young people on the trust intranet. Youngpeople were offered leaflets with information about theirillness and about prescribed medicines and possibleside-effects.

Leaving HospitalStaff ensured parents needs and wishes were taken intoaccount when arranging discharge from the hospital. Aparent in the Special Care Baby Unit (SCBU) said staff hadarranged the discharge plan together at a time to suit themand the rest of their family. Children were discharged withuseful information to assist parents care safely for theirchildren at home. For example parents in SCBU were givenadvice about feeding their babies. Parents in the children'sward and the emergency department were given adviceabout medication and signs and symptoms to be alerted toof any deterioration in their child's health.

Prior to discharge all children with identified mental healthconcerns undergo a full CAHMS assessment. The staff


Good –––


liaised with the children’s health visitor and for youngerchildren the school nurse. We were told if the child hadspecial needs then there was also liaison with communitychildren's nurse teams.

Children’s discharge planning was also discussed to ensureit was safe and the needs of the carer and child were met.For example, one child’s discharge was arranged to ensureparents could attend other hospital appointments.Information discussed at the handover was included in thetreatment records in the patient’s files.

Learning from experiences, concerns andcomplaintsThe trust monitored and analysed complaints frompatients in children's services. They established 0.08% ofpatients who used women and children's services acrossthe trust last year complained, in the main, aboutcommunication. In response to this the trust employedadditional staff.

In the children’s ward we read written feedback frompatients who described their interactions with staff as“helpful.” Parents told us communication with staff workingwith children in the hospital was good. Staff in thechildren's ward told us parents complained about thestandard of food available on the ward. Staff told us disheslike shepherd’s pie was sometimes available twice a dayand wasn't always child friendly or a healthy option. Inresponse the ward reviewed the options available to themto assist them to provide additional healthy food.

Are children’s care services well-led?

Good –––

Vision, strategy and risksNursing and medical staff told us the strategy in children’sservices in the hospital about the delivery of high qualitycompassionate care to patients was in line with the trust’sstrategy and vision. Nursing staff in the Special Care BabyUnit (SCBU) and the children's ward had access to theinformation and guidance about the trust strategy on theintranet. Nursing staff told us workforce planning and caredelivery was regularly discussed at ward meetings and atthe children’s services clinical governance meeting. Nursingstaff in SCBU told us they regularly discussed and followed

trust strategies like the neonatal strategy. A staff membertold us: “It means we work consistently towards sharedgoals. Following strategies like delivering compassionatecare is embedded in our day to day work.”

Risks inherent in the delivery of safe care for children wereclearly identified on the hospitals risk register. For examplein SCBU they identified the need to ensure the correctprescribing, administration and dosage of antibiotics givento babies, following a recent incident. As a consequencethe protocols and checklists were reviewed. Threeadditional checks were put in place to ensure the safeadministration of the medicine. Two monthly audits andspot checks were also put in place.

All risks to safe care for children were discussed at wardmeetings with the ward managers. These were thenescalated to senior staff in the children's services includingthe director for divisional risk and then to the executiveboard for the trust. A nurse in the children’s ward told us: “Ifrisk was high then the corporate risk team in the JohnRadcliffe Hospital would also be involved.” They told us: “Itis a very thorough system.”

Governance arrangementsStaff members in all parts of children's services across thehospital were clear about the monitoring arrangementsand the feedback about performance. Clinical governancemeetings were held monthly. The children's service unit(CSU) monthly meetings included the ward manager fromSCBU, paediatric consultants from the hospital, the clinicaldirector, staff responsible for the maintenance of the riskregister and paediatric staff from the John RadcliffeHospital. These meetings discussed clinical incidents andincidents on the reporting system. The ward manager saidthey invited colleagues across the trust for shared learningon microbiology. A senior nurse in the SCBU and thechildren’s ward went to monthly children’s divisionalmeetings..

Leadership and cultureThe leadership and culture in the hospital encouragedsupportive relationships in staff teams. A senior member inSCBU said it was their role to ensure staff felt supported.They said: “we have an open supportive culture here. It isimportant staff feel supported so we have regular wardmeetings to discuss any issues about the ward and shareany information from the trust.” They said every twomonths senior staff from children’s services in the hospitalmet with senior staff at the John Radcliffe Hospital “where


Good –––


we can voice our opinions and make changes.” They told usthey benefited from the unit being small so they couldaffect change quickly. For example, they introduced asystem where staff were responsible for cleaning certainareas in the unit with a designated checklist. They said: “Ithen know in a 24-hour period everything has beencleaned.”

A staff member said they felt involved in decisions aboutthe future of the unit. The staff duty rota and discussionswith staff members confirmed staff turnover in the SCBUwas low. A staff member said: “People only leave if theyretire or go on maternity leave.”

A senior staff member in the children's ward spokepositively about the consultant-led unit. They described itas: “a close knit department with a strong team ofconsultants who have very close links with John RadcliffeHospital as some of the team are on a rotation to workthere.” Nursing staff spoke of these close ties andconsistent working across the trust which assisted childrenwho moved from the John Radcliffe Hospital to the HortonHospital.

Patient experiences, staff involvement andengagementStaff were involved and engaged in service delivery and theviews and experiences of patients impacted positively onchanges in children's services. All staff including paediatricconsultants told us they felt supported by the hospitalnursing staff and patients were positive about theconsultant-led children's ward and the strong links with theJohn Radcliffe Hospital. A staff member told us: “it meanswe have easy access to speciality advice.”

Staff told us they could express their views in wardmeetings and were confident they would be listened to bythe organisation. We were told parents complained aboutthe effective working of the lift to both the children’s wardand SCBU and it had been repaired quickly.

One parent told us: “The children's ward has a goodreputation locally. We wouldn't want it to close.” Anotherparent told us at our listening event: “I had all my childrenat the hospital and we are thankful we have a goodemergency department for children. I couldn't drive all theway to Oxford if my child had an accident. We worry aboutit closing so I take every opportunity to make my viewsknown.” A member of the local Healthwatch told thehospital was “held in high regard.”

Staff in the children’s ward said children and carers can usethe feedback forms or comment cards to tell them abouttheir service. In the children’s ward the staff told us theylistened to parents’ concerns about healthy eating optionsnot being available for children and a review was inprocess.

Learning, improvement, innovation andsustainabilityStaff in children’s services in the hospital told us they feltincluded in the development of children’s service acrossthe trust. They talked about the “Safe and Sustainable”programme and the increased demand for paediatricsubspecialty services. Information from the trust predictedannual growth for both paediatric endocrinology and forpaediatric neurology. The trust worked in partnership withother trusts to develop a model which intended to provideas much care as possible locally. Staff spoke positively ofopportunities for learning both in the trust and from workwith other trusts.


Good –––


Safe Good –––





Information about the serviceEnd of life care was not provided in a single setting, butintegrated in wards and departments across the hospital.The hospital had a palliative care team providing supportto staff caring for patients at the end of their life or needingpalliative care. The hospital also provided 24-hourpalliative care advice to patients nursing staff and doctorsby phone or visits if clinically indicated to patients.Specialist link nurses on each ward supported staff withday-to-day good practice and updating them with recentguidance.

Summary of findingsPatients received effective and sensitive end of life care.Patients told us they felt safe with the staff and overalltheir needs were met. We were told medicines wereprescribed to control patients’ pain and staff were usingthe fast-track process for early discharge. Patients saidstaff respected their rights: in particular privacy anddignity. Patients and their relatives told us where therewere concerns staff were available for discussions.

Patients at the end of their life were able to makedecisions about the medical procedures to be followedin the event of cardiopulmonary arrest. If the decisionmade was not to attempt to resuscitate the patient, itwas recorded and brought to the attention of allmedical staff involved in the delivery of care.

Patients were treated with compassion and were notexpected to wait for pain medication. Doctorsprescribed medicines in advance to prevent delays inadministering medicines to patients in pain. Medicinesto be taken as required were prescribed to ensurepatients were comfortable between other scheduledmedicines.

Patients were cared for by staff with an understanding ofend of life care. There were nurses on each ward whospecialised in specific topics including end of life care.These staff were able to support other staff who neededguidance or advice. Doctors completed mandatorytraining on end of life care during their teaching.

End of life care

Good –––


Are end of life care services safe?

Good –––

Safety and performanceThe hospital responded to changes in guidance for thedelivery of care. In June 2013, the Oxford UniversityHospitals Trust responded to guidance from theindependent review of the Liverpool Care Pathway andphased the use of this pathway across the trust. Advancecare planning forms developed with the Oxfordshire End ofLife Reference Group followed on from previous end of lifestrategies. This was devised to capture essentialinformation based on the wishes of the patient at the endof their life and act on it. Advanced care planning listed theprofessionals involved in the patient’s care, the diagnosis,the patient’s wishes for the future, and if a decision not toresuscitate had been taken.

Learning and improvementThe hospital learned from incidents and was continuouslylearning. The Quality Account reports 2012/13 for the truststated incident reporting had improved with theintroduction of the electronic reporting system across thetrust. This system had allowed for real-time assessments ofclinical incidents which gave the trust an opportunity toidentify trends and improve patient safety.

Systems, processes and practicesPatients said they felt safe when staff delivered their careand treatment. One patient said: “Yes, my care is verygood.”

Policies were in place to ensure staff followed correctprocedures for patients considered not suitable forresuscitation in the event of a cardiopulmonary arrest. The“do not attempt cardiopulmonary resuscitation (DNACPR)and child and young person’s advance care plan (CYPACP)”policy explained the hospital’s procedure. The policyrequired staff with direct patient contact to discussadvanced decisions with the patient and/or their carers in atimely manner. The roles and responsibilities of staff weredetailed in the procedure and directed the patient’sconsultant to complete do not resuscitate forms for thepatient. Consultants were directed to document thedecision which ensured all staff involved with the patientknew not to resuscitate the patient in the event of cardiacor respiratory arrest.

Forms for resuscitation decisions were in place for patientsat the end of their life. Nursing staff knew it was theconsultant’s responsibility to discuss resuscitation with thepatient and, where appropriate, their relatives. Theresuscitation decision forms (DNACPR) we looked at weresigned by the consultant and included the reasons for thedecision and the people involved in taking it. Staff told uspatients were able to take a copy of their DNACPR forms ondischarge and some patients on readmission returned withtheir form.

Medicines managementPatients were prescribed medicines to manage their pain.One patient said: “I have morphine and the staff say if youare in pain you must take it. I can have it every hour.”Another patient told us their pain was not being managed.We spoke with the ward sister who explained the painmanagement plan in place and explained there had beenan increase in the strength of prescribed pain medicines.The palliative team had recorded in the patient’s notes thedifficulties that may be encountered with managing thepatient’s pain. The medicine chart we looked at confirmedpain medicines had increased and were administeredaccording to the doctor’s directions.

Medicines for symptom control were prescribed in advanceto prevent delays in administering medicines to patients inpain. Nurses on two wards told us it was usual for doctorson their wards to prescribe pain relief early to make surepatients had their medicines over weekends. Medicines tobe given as required (known as PRN medicines) wereprescribed to ensure patients were comfortable betweenother scheduled medicines. A link nurse (a nurse withresponsibilities in specific areas) for palliative care told usdoctors had access to information on the range ofmedicines that could be prescribed to patients at the endof their life.

Monitoring safety and responding to riskThe hospital responded to identified risks. The safety ofpatients in relation to the delivery of medicines wasanother key area for improvement identified by thehospital trust in 2012/13. The safety and security ofmedicines was identified as needing improvement andaudits were undertaken to assess the levels of risk. Staffensured medicine rooms were locked and only those staffwith responsibilities for the administration of medicineshad access to the medicine room. Systems were in placefor controlled drugs (CD) which included, as legally

End of life care

Good –––


required, the maintenance of a CD register. Staff recordedthe CDs held, directions for administration and details oftheir administration. The pharmacist audited the CDregister on a three-monthly basis to ensure safe systems ofmedicine management were maintained.

Staff knew the principles of the Mental Capacity Act 2005.Staff knew where patients lacked capacity to make adecision a formal assessment had to be undertaken. If apatient was assessed as lacking mental capacity, decisionswere taken in their best interests and involved the patient’smedical team and relatives or carers.

Anticipation and planningSome decisions were not recorded to reduce the risk oferror. The “do not attempt cardiopulmonary resuscitation”(DNACPR) forms kept in the front of patients’ files did notindicate where indefinite decisions were made. Aconsultant told us indefinite DNACPR was assumed wherethere was a blank section with no review date in thepatient’s form. This meant there was no clear informationto ward staff for readmitted patients on end of life care.

Are end of life care services effective?(for example, treatment is effective)

Good –––

Using evidence-based guidanceThe standards of care evaluated in the National Care of theDying Audit Hospital (NCDAH) Round 4 2013/14 were basedon the End of Life Care Strategy (DH 2008) and reflectNational Policy Guidance. Compassionate care of the dyingpatient was an essential aim for NHS trusts, andcommissioners wanted evidence of the provisions ofquality care. The audit report for the National Clinical Auditwas expected in 2014.

Patient care was delivered to patients as individuals.Specific end of life care pathways were not used at thehospital since the Liverpool Care Pathways (LCP) wasphased out. The nurses we spoke with told us anindividualised approach was now used for all patients onthe ward. For example, patients received support with theirphysical, emotional and cognitive health. The nursingassessment incorporating activities of daily living carerecords form replaced the LCP monitoring tools. The formswere not appropriate for all situations, as there was limited

space for recording information about palliative care. Thestaff used stickers to identify the nature of the record forexample, nursing procedures and palliative care. The notesshowed staff received guidance on how to meet the needsof patients on end of life pathways.

Performance, monitoring and improvement ofoutcomesThe trust participated in national clinical audits, reviews ofservices, benchmarking and clinical service accreditation.The trust participated in the National Bowel Cancer Auditand various respiratory disease audits; however, there wasno overarching auditing of the end of life care service.

Staff, equipment and facilitiesThe hospital made sure that it had the right skill mix of staff.One patient told us the nurses had explained the care andtreatment to be delivered when they were admitted to theward. We were told the ward staff were “busy but good,”they knew how to care for them and “yes the staff arequalified.”

There were safe handovers between shifts. Ward staff wereupdated on the patient’s condition when they came onduty. They told us there was an overlap of staff forhandovers where all patients were discussed. There werepre-populated handover sheets given to staff when theycame on duty. These sheets included a summary of thepatient’s history, diagnosis and essential information.Essential information included patients identified for fasttrack discharge, those who did not wish to be resuscitated,and patients receiving palliative care.

Ward staff told us people on end of life pathways were ableto continue their care in the ward. Another nurse said,where possible, patients at the end of their life were movedfrom four-bedded bays to side rooms to preserve patients’dignity. Where it was not possible to move patients to siderooms they were moved to quieter bays with fullconsideration given to the patients in the bay.

Multidisciplinary working and supportWard staff told us there was a fast-track process for patientswhose wishes were to be discharged home when they wereat the end of their life. Palliative care staff told us themedical team co-ordinated the patient’s discharge homeand ensured information about the person’s care wasrelayed to community teams. The two patients we spoke

End of life care

Good –––


with were on fast-track discharge and explained thereasons for their onward admission to nursing placements.One patient and their family told us the delay in theirdischarge was caused by funding.

Are end of life care services caring?

Good –––

Compassion, dignity and empathyPatients’ rights were respected by staff. Patients said staffmade sure they pulled curtains when providing personalcare to ensure privacy and dignity were maintained. Thefamily of a patient told us the staff cared for their relative byproviding personal care and monitoring their food anddrink. Another patient and their relatives said the staff werenot always respectful. The ward sister explained meetingswith the family had taken place to resolve some of theconflicts that had arisen.

Staff were aware of the rights of patients. A nurse said theyhad attended equality and diversity training. They gave usexamples on how patients' rights were respected. Forexample, keeping the ward calm and treating patients inthe same way “we would like to be treated.”

Ward staff ensured patients and their relatives were caredfor with compassion. One nurse gave us examples of thecare delivered to end of life patients from other ethnic orcultural backgrounds. This included patients who weretravellers and patients with other religious beliefs. Staff toldus visiting times were more flexible for patients at the endof their life to ensure patients had as much time with theirrelatives as they wanted.

Involvement in care and decision makingPatients made decisions about their care. One patient toldus: “I don’t like people making decisions for me.” Anotherpatient told us they wanted to be better informed by theirconsultant and they knew to make an appointment withthe consultant to discuss their treatment. The ward sisterknew of the concerns this family had. The family of apatient at the end of their life told us they were involved inthe decisions of no further treatment being given to theirrelative. They told us their views not to resuscitate hadbeen sought by the consultant and they had agreed withthe consultant’s decision.

The staff on the wards knew the patients who were on anend of life pathway. Nursing staff said consultants made thedecisions on the status of patients. Once the consultantand multidisciplinary team (including ward staff) hadagreed the decision, the consultant discussed this with thepatient and/or their relatives. The consultant explained tothe patients and their relatives the emphasis of the carewas no longer to cure the patient, but to make themcomfortable at the end of their life. One nurse gave us anexample when joint decisions not to resuscitate were madefor patients who experienced readmissions due to theirmedical conditions. We were told it was common forpatients with chronic obstructive pulmonary disease(COPD) to experience a number of readmissions and thedecision not to resuscitate was reached jointly with thepatient. The specialist palliative team told us they werethen informed of the patient once the decision was madeby the consultant and the patient’s notes clearly indicatedthis decision

Trust and communicationInformation on palliative care was available to patients andtheir families. Ward staff told us information on palliativeservices was available on the hospital website. The hospitalwebsite had online advice and information linked tohospices and other NHS websites. Staff from the palliativeteam told us patients had access to direct contact from thecommunity team for support following their discharge.Written information was also available to patients on Livingwith Life-Limiting Illnesses which gave key information onservices and facilities available to adults in the Oxfordshirearea.

Emotional supportPatients had emotional support from trained staff. Thebereavement officer helped families and carers witharrangements following their relative’s death; helped withfamily conflict; and counselling. Ward staff asked thebereavement officer to visit families and carers, and theyhad strong working relationships with the palliative careteam. Patients and families had access to chaplaincy andclergy from their religious denominations. Staff ensured theviewing room available to families was arranged inaccordance with the patient’s and family’s belief or culture.For example, appropriate books and religious symbolswere made available.

End of life care

Good –––


Are end of life care services responsive topeople’s needs?(for example, to feedback?)

Good –––

Meeting people’s needsPatients were cared for by staff with an understanding ofend of life care. There were nurses on each ward (referredto as “link” nurses) who specialised in specific topicsincluding end of life care. These staff were able to supportother staff who needed guidance or advice. Palliative carelink nurses had a strong working relationship with thepalliative care team and attended meetings arranged bythe team. The meetings discussed good practice whichthey used on the wards. For example, link nurses hadprovided information on the types of medicines suitable forpatients at the end of their life and we saw this informationwas on display in the medicine room. Two nurses told usalthough they had not attended end of life training, theyworked alongside link nurses who offered advice. We spokewith a junior doctor who told us end of life teaching wasmandatory during their training.

Vulnerable patients and capacityStaff were aware that patients at the end of their lives wereparticularly vulnerable and took extra care to ensure thatthese patients understood their care and treatment..

Access to servicesPatients on end of life had access to specialist staff fromthe palliative care team. Staff from the palliative care teamoffered advice and guidance to patients, their families andhealth and social care professionals. Once discharged,patients at the end of their life had access to communitypalliative care staff. The patient’s care and treatment wasreviewed weekly at multidisciplinary team meetings.Patients’ notes we saw recorded advice given on painmanagement and symptom control. One family confirmedtheir relative had home visits from specialist palliativenurses.

Leaving hospitalThe hospital had a fast-track process for patients at the endof their life who wished to be discharged home or to othercare providers such as a hospice or nursing home. The stafffrom the palliative care team told us the fast-track process

was co-ordinated by ward staff. An end of life care checklistwas completed and contained essential information fordischarging the patient to the community palliative careservices.

Learning from experiences, concerns andcomplaintsPatients felt confident about raising concerns. The twopatients we spoke with told us they felt confident to raiseconcerns to the staff. One patient told us they had been onthe ward for five weeks and had no concerns. The otherpatient told us they had complained in the past. The wardsister told us when patients have concerns a discussiontakes place to resolve issues promptly. A meeting had takenplace with the patient and family to discuss their concerns.

Are end of life care services well-led?

Good –––

Vision, strategy and risksThe hospital had a strategy for end of life care. The OxfordUniversity Hospitals Trust Quality Account report 2012/13featured patients experience as a key objective specificallycare of the dying. The identification of patient’s reachingtheir end of life was an area for improvement by the trust.The staffs told us decisions to determine when patientswere reaching the end of their life were made by theconsultants and multidisciplinary team. The patients wespoke with were part of the decision about their care andtreatment. Ward staff and staff from the palliative care teamtold us the systems in place to provide community servicesfollowing patients discharge. Patients told us they had apalliative nurse involved in their care when they were in thecommunity. The two patients we spoke with were onfast-track discharge as they had made the decision not tostay in the hospital.

Governance arrangementsThe Oxford University Hospital Trust reports on mortalityrates as part of their clinical excellence. The Health andSocial Care Information Centre (HSCIC) werecommissioned to gather mortality rates across trusts andEngland. The Oxford University Hospitals stated in theirquality account report that their mortality rates wereapproximately 10% higher because of their inpatientpalliative services.

End of life care

Good –––


Leadership and cultureHospital staff were proud to work for the trust. One nursetold us: “I am proud to be part of the team. We work welltogether.” A link specialist palliative care nurse told us: “Iam proud of what we are doing.” Another nurse told us:“We do end of life care well.” They told us there were stronglinks with members of staff from the palliative care team.

Patient experiences, staff involvement andengagementPatients’ experience was sought through surveys andfeedback to staff. There were Friends and Family testsurveys for patients to give feedback about theirexperiences. These views were used by the trust to improveservices for patients. One family of a patient on end of lifetold us they were aware feedback forms were available.

Learning, improvement, innovation andsustainabilityThe organisation wanted to learn and improve. Lack ofinformation at the discharge stage had been identified by

the trust as needing improvement. The Quality Accountreport 2012/13 accepted some people returned to hospitalbecause they were not given enough information on theirdischarge. The trust identified two areas for improvementsto reduce readmission to hospital which included providingbetter quality of information to patients on what to expectfollowing their discharge. The trust also was to introduce ahelpline managed by specialist nurses offering advice onsymptoms people may experience following theirdischarge.

The key findings in the NHS staff survey for the OxfordUniversity Hospitals were reported in the trust’s QualityAccounts 2012-13. It was reported 77% of the staff had anappraisal in 2012 and 81% job relevant training andlearning development.

End of life care

Good –––


Safe Good –––

Effective Not sufficient evidence to rate




Information about the serviceThe level of outpatient activity provided at Horton GeneralHospital in 2012/13 was 87,610 which accounted for 11.6%of the total trust-wide activity in the Outpatients division.There were 26 different speciality clinics including:neurology, ophthalmology, dermatology, oral andmaxilla-facial, gynaecology, general surgery and medicine,paediatrics, breast care, rheumatology, urology,gastroenterology, vascular, ear nose and throat,haematology, oncology, chest, diabetic and endocrinologyand one access department for planned surgery. Fractureclinics were provided at the weekend to enable patientsfrom A&E to be seen the following day.

Summary of findingsPatients received safe and effective care. Staff wereskilled and caring and knew their responsibilities tokeep patients safe. Risk assessments had beencompleted and actions identified to improve theservice. The clinic was clean and a refurbishmentprogramme had started. Capacity remained a concernbecause demand had increased by 10% over the yearprior to our inspection. The trust was planning toimprove capacity at the hospital by providing twoadditional clinic rooms in the refurbishment. Audits forthe “choose and book” system had taken place and thetrust was in the process of re-profiling outpatients toimprove the patient experience.

We spoke with 10 patients and the majority had noproblem getting an appointment and all tests and x-rayshad been completed in a timely manner. Eight patientswere complimentary about the service and two told usthe service was excellent overall. Two patients hadproblems getting an appointment in a timely manner.

There was a culture between staff to improve thepatient experience and be the best they could be.Patient views and experience had been sought to helpimprove the service. Staff had endeavoured to answerany verbal concerns raised with them immediately.

The trust were keen to develop directly bookableappointments that relieved pressure on staff and thetime it took patients to book individual appointmentsover the phone. The plan was to improve the timeautomatic letters were sent for appointments andcancellations.

Outpatients

Good –––


Are outpatients services safe?

Good –––

Safety and performanceThere were effective arrangements in place for reportingpatients or staff safety incidents and allegations of abuse,which were in line with national guidance. In the last 12months 54 incidents forms had been completed and therewere no red alerts that identified an extreme risk.

We were informed that all staff completed life supporttraining annually and there was resuscitation equipmentavailable. The sister in charge told us there was adequatestaff due to staff being “flexible, helpful, positive, andsupportive”. The staff rotas were different every week tomatch the clinics. Staff had been matched to their skillsand additional staff would be provided when required. Thesister in charge managed staff skills and competencies thatrelated to the specialities in each division.

There was an adult and child safeguarding procedure forstaff to access from the computer and staff had completedsafeguarding e-leaning training every three years.

Learning and improvementThe incidents reported were mainly minor accidents tostaff and patients for example: slips or trips and there hadbeen no actions required. The results from a recent patientquestionnaire were mainly positive and the results wereposted on the wall for patients to see. Individual negativecomments were mainly about waiting times. An audit hadbeen completed to assist an outside company withre-profiling. This was a review of the way that outpatientswas organised and managed, to ensure the capacity withinclinics met increasing demand.

Systems processes and practicesThere were systems to help keep patients safe. Theseincluded risk assessments which had been completed formoving and handling and hand washing. When patientswaited for transport at lunchtime they had a free lunchboxprovided and snacks when doctors were delayed.

The clinic was clean. There was a cleaning schedule for allclinic rooms and staff checked them three times a day andrecorded the result. There were hand gels available forboth staff and patients placed at entrances which werebeing used.

Monitoring safety and responding to riskThere were no major risks to patients. There was a local riskaction plan for outpatients which included three issues forimprovement. These were to replace carpeted areas toimprove infection control, update the clinic couches andreplace a wooden baby changing station. We wereinformed two clinic room floors had been replaced butthere were other areas to finish. All 20 pump actioncouches need updating to electronic couches. The Leagueof Friends were providing two new couches but they hadnot arrived. The trust had agreed to replace the babychanging station and the replacement couches wereoutstanding.

Administration staff were concerned that the corridor theyused to access their office had water was leaking throughthe ceiling and electric cables were visible. We observedthis during our inspection.

Anticipation and planningSome problems with capacity were anticipated in advancebecause the department was generally notified six weeksbefore a clinic was cancelled. The sister in charge had kepta record of when there was no notification. The majority ofchanges to clinics without notification were cancellations.Changes made to outpatient clinics without notificationfrom the beginning of August 2013 until end of January2014 numbered 100. The majority of reasons for cliniccancellations were the doctor was on annual or studyleave, even though they were required to give six-weeks'notice. When clinics were cancelled in advance other clinicswere scheduled to clear the backlog of patients waiting foran appointment.

Are outpatients services effective?(for example, treatment is effective)Not sufficient evidence to rate

Using evidence-based guidanceCare and treatment was delivered in line withevidenced-based guidance. The trust was working withOxfordshire CCG because they were concerned the trusthad a Choose and Book breach rate of over 50% and insome specialties over 95%. The hospital had recentlyprovided additional capacity to see patients in the ear,nose and throat (ENT) clinics to help with the breach rates.

Outpatients

Good –––


Performance, monitoring and improvement ofoutcomesThe trust participated in national clinical audits, reviews ofservices, benchmarking and clinical service accreditation.Staff told us that all appointments were managed bydifferent teams. The Choose and Book system did not takeall referrals. Some were arranged by each department andconsultants managed some of their own referrals. Amember of staff told us that sometimes patients gotmultiple letters for appointments at the hospital. This was afault of the system and was under review. We wereinformed ophthalmology clinics were full with firstappointments which meant follow up appointmentscaused an overload in the clinics.

The trust planned to improve capacity at the hospital byproviding two additional clinic rooms in the refurbishment.Audits for the Choose and Book system had taken placeand the trust was in the process of re-profiling outpatientsto improve the patient experience.

We spoke with ten patients and the majority had noproblem getting an appointment and all tests and x-rayshad been completed. Eight patients were complimentaryabout the service and two told us the service was excellentoverall.

Staff, equipment and facilitiesRisk assessments had been recorded for facilities andequipment. Actions had been recorded and timescales forimprovements had been agreed with the trust. Theoutpatients department was old and drab but the trust hadstarted a refurbishment programme.

Multidisciplinary working and supportThere was a good working relationship within the patientaccess centre where appointments were booked at thehospital. Local GP’s would refer through the Choose andBook system and 90% of patients had an appointmentafter they had called the centre in Oxford at the arrangedtime. If an appointment was not booked then a referral waslogged in the electronic patient record and the patient wasadded to breach list. These were triaged by the consultantto consider whether any tests were required first. Staffcontacted the patient by phone or letter to explain the planand all appointment letters were sent by the Oxford team.Pre-operation information and dates were sent from the

Horton. A member of the administration staff told us therewas usually a queue on the 'Choose and Book' telephoneline but 90% of patients had their choice of time andoccasionally hospital site.

Are outpatients services caring?

Good –––

Compassion, dignity and empathyWe spoke with 10 patients and the majority were pleasedwith the service. We observed that the reception staff werewelcoming and treated patients with respect and kindness.A recent patient survey of 44 patients recorded that 31patients told them communication with support staff inoutpatients was excellent and 12 said it was good.

Involvement in care and decision makingPatients told us that they had investigations in a timelymanner and one patient told us: “Banbury has always beengood”. Patients knew what their appointments were for andthe reason investigations were required.

Trust and communicationPatient records arrived the day before a clinic andinvestigation results were printed from the computer whererequired. Records arrived on time for the clinics. The sisterin charge told us the electronic patient record was indifferent stages in each department and currently they onlyhad access to patients’ investigation results.

Nurses were usually able to chaperone patients andensured that they understood the consultant and repeatthe information if required. Occasionally, a nursesupported four consultants in one clinic and was unable tochaperone everyone. This may mean that patients did notget always get the support they needed. Leaflets wereavailable about treatment and diseases and the doctorasked staff to give them to patients. Consultants hadrecorded medical history, medication, treatment, adviceand follow up appointment in the patient record. Letters toGPs were recorded and sent out within a week with aduplicate to the patient. Patients were able to make furtherappointments in outpatients which was easier and quickerfor them.

Emotional supportStaff checked the results of investigations required andwere mindful should the news be negative and a patient

Outpatients

Good –––


may require additional support. The sister’s office could beused for privacy when required. The staff were experiencedin providing support to patients as most of them hadworked in outpatients for a long time and the sister incharge was confident in their ability.

Are outpatients services responsive topeople’s needs?(for example, to feedback?)

Good –––

Meeting people’s needsThe recent outpatient survey in February 2014 identifiedthat 40 patients out of 44 were satisfied with the care theyreceived in outpatients, three did not respond. Themajority of patients indicated that the verbal and writtencommunication was either excellent or good. A white boardoutside each clinic room indicated to patients how longthey had to wait to be seen. Generally, the staff toldpatients how long they would be waiting. Staff told us that5-10% of patients had waited two hours to see theconsultant.

Vulnerable patients and capacityA telephone interpretation service was used to supportstaff and patients when required. Staff told us it workedwell and was used a lot. Braille and large print leaflets wereavailable. Information in other languages could beprovided. There was no learning disability trained nurse inthe hospital to support patients and staff should the needarise. The trust told us there was a learning disability nursewho worked across all sites where required. The sister toldus that staff had been trained to support patients withdementia care needs.

Access to servicesA patient told us they travelled from north of Banbury toOxford for an MRI scan because there were no facilities forthis at the hospital. We spoke to the manager in radiologyand they told us there were no plans to install MRI facilitiesthere. There was some capacity to use the MRI scanner at atreatment centre nearby but access was difficult forinpatients.

Leaving hospitalPatients were given information they required beforeleaving the department. Patients waiting for transport overlunchtime were provided with a free lunch box.

Learning from experiences, concerns andcomplaintsThe sister in charge told us they did not have many verbalcomplaints and mostly they were about waiting times.There had been issues raised with the Patient Advice andLiaison Service (PALS) about waiting times for outpatient’sappointments. The trust had taken action by conductingan audit of outpatient’s capacity and demand to introducere-profiling of clinics. This is a review of the way thatoutpatients is organised and managed to ensure that thecapacity within clinics meets increasing demand. Therewas a plan to create a four-room paediatric clinic which willfree up two rooms in the outpatients department at thehospital. This would enable additional clinics to take placeand improve appointment waiting times.

Are outpatients services well-led?

Good –––

Vision, strategy and risksThe trust Quality Account recognised waiting times werenot reduced and were working with Oxford ClinicalCommissioning Group (OCCG) to ensure that capacity ofoutpatients was managed well.

The radiology department had a refurbishment plan inplace and changes were being made to rearrange andimprove facilities. All safety precautions had beenidentified and we were told there were detailed plans toensure patient safety at all times.

Governance arrangementsIssues raised in the outpatient department were escalatedto the lead nurse in the operational and servicedevelopment directorate. Outpatient clinic bookings weremade in Oxford for each division. This made it a difficultexercise to follow up the cancelled clinics for each division.Staff felt they were sometimes the poor relation of the trustwhen improvements were required.

Leadership and cultureThere was a culture between staff to improve the patientexperience and be the best they could be. The staff we

Outpatients

Good –––


spoke with were proud of the hospital and worked togetherto maintain a good quality service. Staff felt supported bysenior staff but sometimes felt they rarely saw divisional orexecutive staff. A member of staff told us that they hadcompleted an audit about patient waiting times and clinicdemand and capacity to aid the review in progress by thetrust to improve patient experience.

Patient experiences, staff involvement andengagementPatients’ views and experience had been sought to helpimprove the service. Staff had endeavoured to answer anyverbal concerns raised with them immediately. Patientshad completed surveys about outpatients and the resultshad been posted on the wall for patients and staff to see.The results had been mainly positive.

Learning, improvement, innovation andsustainabilityThe trust set out their transforming patient experiencestrategies for 2014 to 2016. Staff we spoke with told us that

the hospital was currently going through a re-profiling ofoutpatients. This is a review of the way that outpatients isorganised and managed to ensure that the capacity withinclinics meets increasing demand to improve targets. Thetrust used Royal College guidelines to inform the work, forexample; on the number of patients seen and appointmentduration. This was work in progress and had not beenrolled out to all outpatients departments yet.

The finance and performance committee met on 12February 2014 to review the progress of the outpatientre-profiling project. The project aims to match demand andcapacity to secure a maximum six-week wait for newoutpatient referrals and to secure savings. The reviewcompletion is behind plan, but the end of May forimplementation was still in place. Patients, staff and GPcommunications have been developed and circulated.

Outpatients

Good –––


cqc horton report

Documents