cqc john radcliffe 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 Requires Improvement –––

Accident and emergency Requires Improvement –––

Medical care Good –––

Surgery Requires Improvement –––

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

JohnJohn RRadcliffadcliffee HospitHospitalalQuality Report

Headley Way,Headington,Oxford OX3 9DUTel: 01865 741166Website: www.ouh.nhs.uk Date of inspection visit: 25-26 Feb & 2-3 March 2014

Date of publication: 14 May 2014

1 John Radcliffe Hospital Quality Report 14 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 8

What people who use the hospital say 14

Areas for improvement 14

Good practice 15

Detailed findings from this inspectionOur inspection team 17

Background to John Radcliffe Hospital 17

Why we carried out this inspection 17

How we carried out this inspection 18

Findings by main service 19

Action we have told the provider to take 95

Summary of findings


Overall summary

The John Radcliffe Hospital, Oxford is the largest hospitalin the Oxford University Hospitals NHS Trust, with 832beds, and serves a population of around 655,000 people.It provides acute medical and surgical services, trauma,and intensive care and offers specialist and generalclinical services to the people of Oxfordshire. The JohnRadcliffe Hospital site includes the Children's Hospital,Oxford Eye Hospital, Oxford Heart Centre, Women'sCentre, Neurosciences Centre, Medical Emergency Unit,Surgical Emergency Unit, and West Wing. It isOxfordshire's main accident and emergency (A&E) site.The trust provides 90 specialist services and is the leadhospital in regional networks for trauma; vascularsurgery; neonatal intensive care; primary coronaryintervention and stroke. It also works in collaborativenetworks with Stoke Mandeville, for specialist burnsservices and with Southampton for paediatric specialistservices in cardiac care, neurosurgery, and critical careretrieval.

The hospital is registered to provide services under theregulated activities:

• Assessment or medical treatment for persons detainedunder the Mental Health Act 1983

• Diagnostic and screening procedures• Family planning• Maternity and midwifery services• Nursing care• Personal care• Surgical procedures• Termination of pregnancies• Treatment of disease, disorder or injury

Many of the services provided by the John Radcliffehospital were delivered to a good standard, but overallthe hospital required improvement. The hospital wasfailing to plan and deliver care to patients needing A&E,surgical and outpatient care and to meet their needs andensure their welfare and safety. Patient records were notbeing completed in some areas of the hospital.

Shortages of staff within the maternity department, onsurgical wards and in operating theatres meant that staffwere not able to provide the best care at all times. Therewere not sufficient numbers of qualified, skilled, or

experienced staff to meet patients’ needs at all times. Thetrust delivers a number of induction programmes for newstaff. However, some staff we spoke with did not alwaysfeel appropriately inducted or supported.

StaffingAlthough in many areas of the trust there were sufficientstaff to meet people’s needs this was not the case in thematernity department, surgical wards and operatingtheatres.

The trust told us that they had difficulties recruiting staffbecause of the high cost of living within Oxford andbecause of the difficulties and cost of parking on thehospital site. The trust told us there had been arecruitment drive and a recent cohort of registered nursesfrom Spain had recently started work. Recruitment wasongoing and further recruitment drives in Scotland andWales were planned.

There were nursing and healthcare assistant staffshortages reported on surgical wards and in theatres. InDecember 2013 the vacancy rate for nursing staff was16.4% in the neurosciences, orthopaedics, and traumaand specialist surgery division. We saw evidence ofpatients who were fit to be transferred from the intensivecare unit onto a surgery ward, but because of staffshortages, there were no beds available in the surgicalwards. This put pressure on staff to discharge patients tocreate capacity.

In theatres the vacancy rate for nursing and medical staffwas 19% in January 2014. There was regular use oftemporary (bank and agency) staff. Staff told us theyworked long days or did overtime on the bank. However,many staff were fatigued and were volunteering less. Staffreported high levels of stress and low morale due toworkload.

We were told that operating lists were cancelled aboutonce a week due to staff shortage. Theatre staff told usthat sometimes theatres had only two theatre staffsupporting the surgeon and anaesthetist. The Associationfor Perioperative Practice (AfPP) recommends that thereshould be three staff (three nurses or two nurses and one

Summary of findings


operating department practitioners (ODPs). Staff in themain theatres told us that they regularly had only twostaff. They said this occurred approximately once a week.They said this had the potential to be unsafe.

In neurosurgery junior doctors told us that sometimes themedical staffing levels felt unsafe. Out of hours there wasone junior doctor (Senior House Officer) looking after 74inpatients, while a registrar provided emergency cover.There was no phlebotomy service, which added further totheir workload. We saw this in practice during ourunannounced visit.

In maternity services the delivery suite had been withouta manager for 18 months. Elements of the role were beingcovered by three band 7 midwives over three days aweek. The trust had attempted to recruit to this role.Although the delivery suite provided women in labourwith one to one care, staffing levels were not alwayssufficient to ensure women received the care and supportthey needed. Where recruitment to new posts occurredthis was of newly qualified midwives who needed supportfrom the experienced midwives within the department.This added further pressure to those staff. In addition,newly qualified midwives reported not receivingadequate preceptorship. The number of supervisors ofmidwives was below that recommended in nationalguidance from the Nursing and Midwifery Council. Therewas not sufficient consultant presence within the deliverysuite to meet national standards, although midwiferystaff reported that consultants were supportive.

Staffing levels had been recently increased on medicalwards due to audit and assessment of patients’ needs.We were told that this had improved morale on thewards.

Cleanliness and infection controlWithin the hospital there were suitable infection controlprocedures and practices. Hand-washing facilities wereclearly indicated in departments and hand sanitising gelwas placed appropriately. Staff said they had enoughpersonal protective equipment including gloves andaprons. In most areas nursing staff were wearing standarduniforms and all staff we saw were adhering to infectioncontrol protocols (such as being “bare below the elbow”,without nail varnish, and wearing minimal jewellery).

Infection control procedures, for example, hand hygieneand cleaning audits, were undertaken monthly and theresults displayed in specific areas of hospital. Thehospital was clean. We saw staff washing their hands andwearing aprons and gloves. On the adult intensive careunit hand hygiene was assessed at only 87% completedand cleaning at only 83%. The matron advised thatongoing works takes place to review all areas audited. Weobserved good hand hygiene taking place in all areas.However, we noted that staff in intensive care did notadhere strictly to the uniform policy with hair touchingcollars and earrings which was not in line with the trustpolicy.

The level of hospital acquired infections was monitoredwithin the hospital. Reported Clostridium Difficile andmethicillin resistant Staphylococcus Aureus (MRSA)bacteraemia were within expected limits. Each reportedcase underwent an in-depth review, and were discussedat the infection control committee. We saw good practicein the children’s A&E department where a child withchicken pox was cared for in a cubicle.

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?We found the services at the hospital were safe however some improvementswere required. Staffing in maternity, operating theatres and on surgical wardswas not sufficient to meet people’s needs. This was recognised by the trust.However, they were finding it difficult to recruit staff because of the cost ofliving in Oxford. Some patient records did not provide sufficient information tostaff about how to support patients. This could mean that patients’ care wasnot as effective as it could be.

Although there was reporting of incidents within the hospital, learning fromincidents was variable. In some areas there was clear learning which had beenshared and disseminated to staff. However, in others it was not clear thatlearning or awareness that incidents had occurred. This included learningfrom never events in operating theatres at the Churchill hospital. Despite two‘never events’ occurring in May and August 2013 within theatres, three theatrenurses we spoke with had no knowledge of never events or serious incidentsoccurring in theatres. It was noted in the investigation report of the secondnever event in December 2013, that there had not been widespreaddissemination of information about the first never event.

Monitoring of safety occurred throughout the hospital. This includedmonitoring of pressure ulcers, falls, venous thromboembolism and patientswith catheter related urinary tract infections and action to minimise theoccurrence of these.

There were suitable arrangements in place to safeguard children andvulnerable adults from abuse. Staff were aware of reporting processes. Therewere also processes in place to monitor and identify when a patient’scondition deteriorates. This was tailored to the patient needs within thehospital divisions.

Requires Improvement –––

Are services effective?Outcomes for patients were good and the hospital performed well whencompared with other similar organisations. Care and treatment was deliveredin line with most national guidance and best practice. Adherence to guidancewas monitored in divisional areas and reported through the governancesystem within the hospital. Staff worked in multidisciplinary teams with carefocused around the patient. Although adherence mandatory training wasgood within the hospital, in some areas staff had not received specific trainingto support people with dementia or a learning disability.

Good –––

Are services caring?In most areas of the hospital we observed staff providing care withcompassion and treating patients with dignity and respect. Privacy wasrespected and curtains were pulled around patients’ beds while care was

Good –––

Summary of findings


being provided. Most patients spoke positively about the kindness and careprovided by staff. However, at busy times within the A&E department somepatients were not made to feel safe or comfortable. We saw patients beingplaced in an atrium or corridor at the front of the A&E entrance before movingto a ward or going home. Although patients were unhappy about waiting inthis area, they said the nursing staff had been fantastic.

There were privacy issues within the A&E department. People could be heardproviding personal information at the reception desk and most of those wespoke with said they felt they had to provide information to the reception staffabout why they were visiting the department.

Emotional support was provided to patients and their families in all areas ofthe hospital.

Are services responsive to people’s needs?Patients experienced difficulties in accessing services to meet their needs in atimely manner within A&E, surgery and outpatients because national targetsfor waiting times were not met. Patients were not provided with suitableinformation about the waiting times in A&E and outpatient departments.

Bed occupancy within the hospital was at a level which had an impact on thequality of care and caused A&E to miss waiting time targets. The A&Edepartment did not have capacity to meet patient’s needs at all times. Theresuscitation room only had provision for four patients at any one time.However, staff said they had been required to use this space for more patientsand to “share” the equipment.

There was a lack of awareness of vulnerable people within the A&Edepartment. We observed a lack of support for a patient with dementia, whowas restrained by security guards. Equally there was not suitable attentionpaid to the identification, assessment and planning of care needs forvulnerable patients within surgery and in some medical wards.

There was a lack of capacity within operating theatres in the hospital. Thehospital was working towards achieving national targets in relation to waitingtimes for operations, cancelled operations and delayed discharges and scoredsimilarly to expected when compared with other trusts. However, staff saidthat operations were regularly cancelled due to lack of theatre capacity,shortage of staff or inefficient planning. They said there were issues aroundthe management of the waiting time target which led to theatre lists beingoverbooked. There were dedicated emergency theatre sessions and anemergency bookable theatre list process which was monitored throughmonthly reporting to the trust board. However, we were told that if emergencycases arose, planned surgery was cancelled.

Similarly in outpatients, “referral to treatment” targets were not being met,with patients waiting longer than agreed standards for outpatientappointments. There were not enough appointments to meet demand andclinic “templates” (which set out the number of appointments in each clinic)


Summary of findings


did not reflect that demand following year on year increases. Clinics wereoverbooked causing long waiting times. The hospital was also not meetingstandards within the Choose and Book service. The impact on these systemswas that patients may experience late cancellations of appointments ormultiple letters which proved confusing. Work to reprofile (redesign) clinictemplates had been in progress since May 2013 and was on schedule.

Are services well-led?Overall the services within the hospital were well led. There was a clear trustvision and a set of values, which were patient focused. Staff in some areas didnot know what the vision and values were but portrayed similar values andpassion and motivation to provide excellent patient care.

Leadership within divisions and departments was generally good with staffsaying they felt supported by their immediate line managers. Among staff,there was variable feeling about the accessibility and visibility of executivelevel management within the hospital. Some staff did not know who theirdivisional lead was or who to contact with any board level questions. Othersdid not feel they were visible or accessible. We were approached prior, duringand following our inspection by senior clinicians (doctors and nurses) workingin surgery within the hospital who felt they were disempowered and did nothave a voice.

There was a clear governance structure with reporting lines from departmentsthrough directorates and divisions, ultimately to the trust board.

Good –––

Summary of findings


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

Accident and emergencyThe A&E department at the John Radcliffe Hospital provided safe care topatients. The local leadership in the department was strong. Staff told us, andwe observed, strong and committed leadership and support from the matron,the consultants, and the senior nursing staff team. Staff told us they felt part ofa team who cared for and supported one another.

Most patients were treated with consideration but care in the emergencydepartment was not always effective to meet patients’ human rights. Staff saidthey had not been trained to support and effectively care for people withdementia. On our visit we observed the restraint of an elderly person withdementia who had been waiting in the department for eight hours. Staff werenot clear about whether there was a pathway for checking on a patientfollowing restraint or documenting its use.

Most staff were well supported, trained and experienced. Some support fromother departments was slow to be delivered due to the pressures on thewhole hospital. This, and the pressure on available bed space, resulted inpatients waiting more than they should for discharge onto wards for morespecialist care.


Medical care (including older people’s care)Staff provided a safe service to patients receiving medical care. Systems werein place to report, respond, and monitor safety issues across all levels ofmedical care. Safe staffing levels had recently been reviewed and severalmedical wards had increased their staffing to support the needs of frail, elderlypatients. Recruitment of staff to medical wards had been successful and thehospital continued to recruit into vacancies.

Integrated care pathways for those patients who had suffered a stroke were inplace and performance was monitored to improve the service being provided.Action plans were in place to ensure sufficient rehabilitation therapists wereavailable to improved patient outcomes. Integrated care pathways forinpatients with diabetes were still being formalised. Diabetes affects 14.7% ofall adult inpatients in the trust. The diabetes quality group was responsible forthe monitoring and delivery of the “Think Glucose” project to improve thequality of care.

Some patients had multiple health, social and/or psychological needs, whichrequired the input of several specialist teams. The multidisciplinary teams inthe division were well integrated and had a strong collaborative approach tocare. Care and treatment that was agreed and delivered was not alwaysrecorded. A written record was not always available to all parties to ensurecontinuity of care.

Staff were caring. Patients and relatives told us they were treated with dignity,compassion, and respect. Patients were involved in planning their treatment

Good –––

Summary of findings


and staff knew how to protect the rights of patients who lacked capacity tomake decisions about their treatment. Efforts were made to ensure patientsstayed in contact with friends and relatives. The hospital had taken account ofrelatives concerns and action plans were in place to improve communicationbetween staff and relatives.

The hospital staff faced significant challenges when discharging patients tocommunity services. It was working with stakeholders to deliver the dischargeimprovement programme. Additional resources had been made available tothe medical wards to improve internal and external discharge arrangements.These included the recruitment of discharge planners responsible forco-ordinating patients’ discharge.

The hospital’s supported discharge service enabled patients who no longerneeded the hospital environment to be cared for at home while waiting forlocal authorities to set up care packages. Ward staff had developed effectiverelationships with transport and care providers to facilitate discharge.

The service was well-led. Clearly defined governance arrangements were inplace in the division which led to improvements in quality. Staff felt supported,valued, and proud to be part of the organisation. Opportunities were availablefor staff to develop their leadership skills. Patients and staff informed servicedelivery and their views were understood at trust board level.

SurgeryThere was consensus among patients, carers, and staff that staff werededicated and provided compassionate, empathic care. However, there wasfrustration expressed by many staff at all levels that they were not always ableto provide safe and effective care. This was due to a lack of capacity, broughtabout by insufficient resources, work flow, and inefficient management.

Pressures within the wider health economy presented significant challenges interms of demand versus capacity. There was evidence that the hospital wasworking with other partners to respond to this but pressures werecompounded by significant and ongoing staff shortage and management ofresources.

There was an overwhelming sense of discontent expressed by senior cliniciansthat the trust board was motivated by financial, rather than by clinicalmotives. This was at odds with the one of the stated values of the trust;“putting patients at the heart of everything we do”. We saw evidence of strongclinical leadership at a local level but senior clinicians felt disempowered andbelieved they had no voice. We saw evidence of good team working at wardand departmental level but there was silo working across sites and divisions.


Summary of findings


Intensive/critical carePatients received safe and effective care. While staff recruitment and retentionwas recognised by the senior staff as an issue, the levels and skills of staff on aday-to-day basis were consistently managed. Clinical outcomes weremonitored and demonstrated good outcomes for patients.

Patients and relatives told us the caring, consideration and compassion ofstaff was of a very high level. Considerable work had recently been undertakento improve the responsiveness of the service to ensure patients weredischarged when they were ready and delays were minimised. This alsoimproved the responsiveness for pre-planned admissions following surgery totake place. The departments were well led and demonstrated a positiveleadership and culture. A business case had been submitted to the trust boardfor future improvements for an increase in high dependency beds to meet theidentified demand as the service sometimes runs at over 100% capacity.

Good –––

Maternity and family planningWomen received care and treatment from caring, compassionate, and skilledstaff. We received positive comments from women and their families about thecare and support they received.

The delivery suite had been without a manager for the 18 months prior to ourinspection due difficulties in recruitment. Elements of this role were beingcovered by three band 7 midwives, but this did not provided consistency in themanagement of the delivery suite. Although the delivery suite providedwomen in labour with one-to-one care, staffing levels were not alwayssufficient to ensure women received the care and support they needed.Recruitment that had occurred was of newly qualified midwives who neededsupport from the experienced midwives within the department. This addedfurther pressure to those staff. In addition newly qualified midwives reportednot receiving adequate preceptorship. There were insufficient supervisors ofmidwives in post to meet guidance from the Nursing and Midwifery Council.There was insufficient consultant presence within the delivery suite to meetnational standards, although midwifery staff reported that consultants weresupportive.

Despite this the maternity service was effective. Care and treatment wasmostly provided in line with national guidance, with the exception of a highernumber of forceps deliveries and best practice with regards to supporting newmothers with breast feeding was not always followed.

The patients were safeguarded from the risk of abuse. Staff had receivedtraining in safeguarding and were aware of the process to report any concerns.These ensured patients were not put at risk as appropriate safeguards were inplace.

Good –––

Summary of findings


There were systems in place for the safety of the patients and staff. There wasequipment for the safe management of a range of patients which includedsome larger tables in the theatres and larger beds in the unit. Training andsupport for the staff was promoted to ensure safe working practices.

Women and their partners told us they were treated with kindness andreceived compassionate care from staff, although the hospital had lower thanexpected scores in the friends and family tests. They received sufficientinformation in order to make informed decisions about care.

The maternity unit was clean and staff followed the internal procedures forhand washing. 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.

The service was responsive to women and their babies’ needs. There wascohesive multidisciplinary working; staff commented this worked well withgood support from clinicians at all levels which, in turn, had positive impactson patients care.

There were clinical governance strategies and regular meetings which lookedat development of the service. Staff felt supported within the ward and units;however, they told us they felt disconnected from the wider organisation.

Despite the absence of a manager in the delivery suite, the service was wellled. Staff reported that they felt supported by their immediate line managersand there was suitable governance processes in place.

Services for children & young peopleWe visited all the wards in the children hospital including the paediatricintensive care unit (PICU), the paediatric high dependency unit (PHDU) andthe neonatal intensive care unit (NICU). We spoke to 45 members of staff. Thisincluded health care assistants (HCAs), student nurses, staff nurses, midwives,senior nursing staff, doctors, registrars, consultant, and anaesthetists,operating department practitioners, nurse practitioners, administration staff,physiotherapists, and play specialists. We also spoke to 14 parents andrelatives, three children and two young people.

Parents, children, and young people were positive about the care and supporttheir received. They told us they were kept informed and involved in makingdecisions. Staffing levels were considered when managing the number of bedsavailable to be used. The trust was aware of areas were additional staff wererequired and they were actively recruiting to these areas. Staff told us they feltsupported and the children’s hospital was a good place to work. There weresystems in place to ensure children at risk of harm or considered to be ofconcerns were identified and protected if seen in the hospital. Staff wereaware of how to report incidents and this information was monitored,reviewed and learning shared with the staff. There was an established

Good –––

Summary of findings


governance system in place that included monitoring complaints, incidents,outcomes from audits and the adherence to national guidelines. Youngpeople’s opinions and input was actively sought through the Young People'sExecutive.

End of life carePatients received safe and effective end of life care based on evidence basedguidelines, national standards, and protocols. Staff were caring andmotivated. They demonstrated commitment to meeting patients’ end of lifeneeds and to supporting patients’ relatives at this time.

A specialist palliative care team was based in the hospital and providedadvice, training and support to hospital staff Monday to Friday. 24-hour,specialist advice was provided by staff at Michael Sobell House hospice, basedat the Trust’s Churchill Hospital. The hospital palliative care team were part ofa wider specialist team who worked collaboratively across the Trust’s fourhospital sites and in the local community. A member of the team was theNational Director for End of Life Care and chair of the Leadership Alliance forthe Care of Dying People.

Feedback from patients receiving end of life care, and their relatives, waspositive. They were well informed, had been asked what was important tothem, and were involved in decision-making. They told us that staff weresensitive to their needs and treated them as a whole person.

Good –––

OutpatientsPatients received safe care because risks to patients were understood andwere being managed. Hospital policies were based on national standards andevidence-based guidelines and adherence with these was monitored. Anuncommissioned 10% rise in demand for outpatient appointments over thepast year meant the Trust struggled to meet national standards for referral totreatment time (RTT) for patients. The trust agreed to fail RTT targets forJanuary, February, and March 2014 with the NHS Trust Development Authority,who provide oversight and governance for all NHS trusts, to enable patientswho had been waiting longest to be prioritised. This meant that patient safetywas prioritised over meeting targets.

Patients were unable to book into appointments using the Choose and Booksystem on 50% of attempts as this could not be done online and there werenot enough administrative staff available to answer calls and make bookings.This resulted in poor experiences for some patients when trying to bookappointments, to make queries or change appointments. The way clinics wereset up in booking systems did not make the best use of clinic facilitiesavailable, which meant that patients sometimes faced unnecessarily longwaits to be seen in clinic. In order to address capacity issues, a trust-wideproject was in progress to increase the number of appointments available andto ensure that clinic facilities were used more efficiently. This project was onschedule and was due to be rolled out to clinics in May/June 2014.

Good –––

Summary of findings


Clinics and waiting areas were clean and well-maintained but space waslimited, which meant waiting areas were often overcrowded. Initiatives were inplace to improve the experience for patients and keep them informed ofwaiting times but these were not used consistently in all clinics.

Despite administrative challenges, patients were highly complimentary aboutthe clinical care they received. Staff were appropriately trained, motivated,and worked well together to ensure that outcomes for patients were good.

Summary of findings


What people who use the hospital say

The hospital trust was rated about the same as othertrusts in the 2012 Adult Inpatient Survey. It performedabove the national average in the inpatient and the A&Edepartment Friends and Family test, although the rate of

return for the A&E test was poor. The trust was rankedbetter than other trusts in five out of 69 questions in the2012/13 Cancer Patient Experience Survey, and onlyworse than other trusts in two of the questions.

Areas for improvement

Action the hospital MUST take to improve

• Staff in the A&E department must have effectivetraining for caring and supporting people presenting inthe department who have dementia or a learningdisability.

• The trust must ensure that nurses coming fromoverseas to work in the A&E department, receiveinduction to ensure their competencies are evaluatedand they are trained in any procedures they areexpected to carry out but have not been previouslyundertaking.

• The flow of patients through the hospital must beimproved to enable the A&E department to meetwaiting times and enable patients to have timelyaccess to specialist care and treatment.

• Patients must be treated with confidentiality, privacyand dignity at all times in A&E triage and when waitingto be discharged from the department

• The trust must ensure that adequate staffing levels areconsistently maintained within the maternitydepartment, on surgical wards and in operatingtheatres.

• The trust must take steps to improve theatre capacitymanagement to ensure that patients do not wait toolong for appropriate care and treatment.

• The trust must improve the quality of care plans toensure that they reflect patients’ individual needs. Inparticular the trust must ensure that the care needs ofolder people and those with dementia are promptlyidentified, and care planned to meet those needs.

• The trust must take steps to improve access topatients requiring outpatient appointments in order tothat they do not wait too long for appropriate care andtreatment.

• The trust must ensure that midwives receiveappropriate supervision and newly qualified midwivesare appropriately supported.

Action the hospital SHOULD take to improve

• The trust should evaluate the provision ofresuscitation beds in A&E so they are meeting theneeds of patients at all times.

• Staff in the A&E department should ensure thatpatients who have dementia are treated with care andthe challenges of their condition considered within thecontext of receiving emergency care.

• Staff in the A&E department should be made aware ofcomplaints from patients to enable them tounderstand the need for changes and improve theirpractice.

• The bed meetings should conclude with actions forstaff and departments to take to proactively manageidentified pressures.

• Some specialist departments should work moreco-operatively with the A&E team.

• The response to the Friends and Family test should beimproved in A&E and Maternity.

• The trust should ensure that patient recordsaccurately reflect the care and treatment that hadbeen planned and agreed for each patient in line withclinical guidelines and good practice standards,especially for those patients who cannot direct orinform staff of their needs.

• Identified shortcomings in the care and treatmentpathway of inpatients with diabetes were beingaddressed but the trust needs to ensure thatoutcomes are delivered to these patients in line withgood practice and clinical guidelines.

• The trust should continue making improvements tothe internal and external discharge arrangements sothat people who do not require a hospitalenvironment are discharged to community servicestimely and effectively.

Summary of findings


• The trust should continue to ensure that positiveoutcomes are delivered for frail, elderly patients andthose with dementia, especially when working withrelatives/carers.

• The trust should continue with their plans to ensuresufficient therapeutic staff, like speech and languageand physiotherapists are available to meet patients’needs in a timely manner.

• The recording of patients observations could beimproved to ensure the plan of care is followed andany changes in patients’ conditions are quicklyidentified and actions taken.

• The trust should ensure that lessons learnt fromserious incidents are promptly disseminated andembedded in practice.

• The trust should ensure that issues relating to thesafety and suitability of premises and equipment inthe main theatres are promptly resolved.

• The trust should take further steps to engage with staffand investigate reasons for disempowerment and lowmorale within the surgical domain.

• The hospital should ensure a better environmentwithin critical care.

• The Trust should reduce the number of delayedtransfers from ICU due to the limited high dependencybeds within the hospital.

Good practice

Our inspection team highlighted the following areas ofgood practice:

• There was strong leadership in the A&E departmentfrom the experienced, caring, and professional matronand sisters.

• The system the trust used to identify and managestaffing levels was effective and responsive to meet theneeds of the hospital except on surgery wards,operating theatres and in maternity.

• There were good care pathways for patients attendingthe A&E department following a stroke.

• The A&E department recognised its pressures and hadbeen proactive in looking for ways to be more efficient.

• The risks and challenges facing the A&E departmentwere well understood by staff and there was an activegovernance framework, which included an excellenturgent care meeting every two weeks.

• The acute stroke service provided by the MedicalDivision was recognised for its treatment pathway anddelivering good outcomes to patients.

• There was a strong sense of improving the outcomesfor frail elderly patients and those with dementia onthe medical wards. The psychological medicineservice was supporting staff to understand the careand support needs of these patients. Wards on level 7were being redesigned to make it more accessible forpatients with dementia.

• Caring compassionate staff throughout the hospital.

• Staff were caring and hardworking in medical areasand many were experienced, compassionate, andchampions for their patients. They spoke highly oftheir colleagues and management.

• Managers of medical areas had a strongunderstanding of the risks in the service andimprovements required. Incident reporting andmonitoring was well managed and the learning fromincidents was evident. There was a strongcommitment, supported by action plans, to improvethe service.

• Staff worked well between teams. The value of aneffective multidisciplinary approach, in improvingoutcomes for patients, was understood and activelyencouraged.

• It was evident that significant efforts had been beingmade to improve the effective discharge of patientswithin medical areas. The hospital was working closelywith commissioners, social services, and providers toimprove the transfer of patients to communityservices.

• Two gerontologists worked in trauma wards to providemedical input and an integrated approach to traumapatients who were older people with co-existingillnesses.

• The nurse consultant in trauma care. This was the firstsuch appointment in the UK and enabled thefacilitation and co-ordination of shared care forcomplex trauma patients.

Summary of findings


• The acknowledgement of excellence of junior medicalstaff within the trauma directorate by leaders.

• The trauma service in general was praised by patientsand staff. It was well led with well-supported staff andhappy patients.

• There was good learning from incidents within criticalcare which translated into training and safer practice.

• The approach to caring for adolescents, within anenvironment designed to meet their needs and a clearteam approach.

• Involvement of young people in developing artworkwhich was made into posters to promote the valuesthat are important to the young people themselves.

• Patients within maternity expressed a high degree ofsatisfaction about the care they were receiving and thestaff who supported them.

• Patients had the expertise of specialist midwives suchas diabetes, breast feeding to ensure they receivedappropriate care and treatment.

• Patients received care in a compassionate way whichincluded a designated bereavement suite and pastoralcare in the maternity unit.

• There was good multidisciplinary team working for thebenefits of mothers and their babies

• There were processes in place throughout the hospitalwhich took into account patients’ diversity. Theseincluded interpretation service and informationprovided in different formats according to the patients’needs.

• The trust internal peer review process, in which over100 clinical areas had been reviewed in a three monthperiod across the trust.

Summary of findings


Our inspection teamOur inspection team was led by:

Chair: Dr Chris Gordon, Consultant Physician, Medicineand Elderly Care, Hampshire Hospitals FoundationTrust; Programme Director NHS Leadership Academy

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

The team of 51 (31 of which inspected this location)included CQC inspectors, managers and analysts,consultants and doctors specialising in emergencymedicine, obstetrics and gynaecology, oncology,diabetes care, cardiology and paediatrics. It alsoincluded junior doctors, a matron, nurses specialising incare for the elderly, end of life care, children’s care,theatre management, cancer, and haematology andtwo midwives together with patient and publicrepresentatives and Experts by Experience. Our teamincluded senior NHS managers, including two medicaldirectors, a deputy chief executive, and a clinicaldirector in surgery and critical care.

Background to John RadcliffeHospitalThe John Radcliffe Hospital, Oxford, is the principalprovider of acute services for Oxfordshire. It is a large-sized

teaching hospital providing acute, specialist andcommunity healthcare to the people of Oxfordshire. Thehospital has a 24-hour emergency department andmaternity service. It serves a population of around 655,000people. There are around 832 beds and the trust seesaround 186,000 patients as inpatients each year, themajority at the John Radcliffe Hospital. The trust arrangesaround 878,000 outpatient appointments each year.

The Oxford University Hospitals NHS trust hasteaching-hospital status as part of Oxford University. Thetrust employs around 11,000 staff, most who work at theJohn Radcliffe Hospital.

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, OxfordUniversity Hospitals Trust was considered to be a mediumrisk trust and is an aspirant foundation trust.

JohnJohn RRadcliffadcliffee 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


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• Children’s care• 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 an announced visit on 25 and 26 February2014. During our visit we held focus groups with a range ofstaff in the hospital, including nurses below the role ofmatron, matrons, allied health professionals, juniordoctors, student nurses, consultants and administrationstaff. Staff were invited to attend drop-in sessions. Wetalked with patients and staff from all areas including thewards, theatres, outpatients departments and the A&Edepartment. We observed how people were being caredfor, and talked with carers and/or family members. Wereviewed personal care or treatment records of patients.We held a listening event where patients and members ofthe public shared their views and experiences of thelocation.

An unannounced visit was carried out on 2 February 2014during the afternoon and evening and 3 February 2014during the day.

Detailed Findings


Safe Good –––

Effective Not sufficient evidence to rate

Caring Requires Improvement –––

Responsive Requires Improvement –––

Well-led Good –––

Information about the serviceThe Accident and Emergency (A&E) department was largeand open 24-hours a day, seven days a week to provide anemergency service to the people of Oxford and thesurrounding areas. The department treated people withboth minor and major injuries and illnesses and was part ofthe Major Trauma Network in the South of England. About120,000 patients (adults and children) were expected toattend the department each year. The department triagedpatients as they were admitted to ensure they were quicklyassessed for the need for any urgent intervention. Thedepartment used the adjacent Emergency Admission Unit(EAU) for patients who needed ongoing observation orassessment before they were admitted to hospital,transferred, or discharged. The department had a ‘minors’unit (for treating minor injuries or illnesses) and ‘majors’unit (for treating major injuries or illnesses) and a separatepaediatric A&E unit which saw around 19,000 children eachyear.

We visited the adult A&E department on a Tuesdayafternoon and Wednesday during the daytime and againon a Sunday evening as an unannounced visit. Duringthese visits we talked with around 30 patients. We spokewith staff, including nurses, doctors, consultants, supportstaff, and ambulance personnel. We visited the paediatricA&E department, the Children's Clinical Decision Unit, andthe minor injuries department on a Tuesday morning andagain on a Sunday evening as an unannounced visit.

We received information from our listening events and frompeople who contacted us to tell us about their experiences.We collected comment cards from a designated box set upfor our visit. Before our inspection we reviewedperformance information from, and about the trust.

Summary of findingsThe A&E department at the John Radcliffe Hospitalprovided safe care to patients. The local leadership inthe department was strong. Staff told us and weobserved there was strong and committed leadershipand support from the matron, the consultants, and thesenior nursing staff team. Staff told us they felt part of ateam who cared for and supported one another.

Most patients were treated with consideration but carein the emergency department was not always effectiveto meet patients’ human rights. Staff said they had notbeen trained to support and effectively care for peoplewith dementia. On our visit we observed the restraint ofan elderly person with dementia who had been waitingin the department for eight hours. Staff were not clearabout whether there was a pathway for checking on apatient following restraint or documenting its use.

Most staff were well supported, trained andexperienced. Some support from other departmentswas slow to be delivered due to the pressures on thewhole hospital. This, and the pressure on available bedspace, resulted in patients waiting more than theyshould for discharge onto wards for more specialistcare.

Care was delivered with consideration and respect bystaff. However, the triage of patients and the use of theatrium as a holding area prior to transfer or dischargedid not provide privacy and dignity. Privateconversations were overheard in the triage area and atreception.

The department was not meeting patients’ needs at alltimes. The four-bedded resuscitation area was, we were

Accident and emergency



told by staff and the local ambulance personnel,sometimes full, and this compromised the delivery ofcare. Most patients we met said they waited for longperiods to see the doctor. Staff had, nevertheless,worked hard to reduce pressure and come up withinnovative solutions to improve the service. Thepressure on the A&E department was predominantlydue to a lack of available beds in the department. Datathe trust provided about the number of breachesshowed the department breached the target for 95% ofpatients to be seen within four hours in seven months of2013.

Are accident and emergency servicessafe?

Good –––

Safety and performancePeople were protected from abuse and staff were trained todeal with suspicions of abuse. Training records showedalmost all staff, including housekeeping staff, were trainedin safeguarding vulnerable adults, and this was a topic forall new staff at induction. Staff were able to tell us how theywould recognise signs of potential abuse and how theywould report this to safeguarding teams. Staff knew theyhad a duty to raise an alert if they were concerned aboutthe safety of any patient or someone accompanying them.

Mandatory training for staff was on track. 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 wasresuscitation. Health and safety and safeguarding, forexample, were updated every three years. We saw recordsfor mandatory training for nursing staff and these wereclear and comprehensive. The hospital used an electronicstaff record system where staff were alerted to any trainingdue for updating. Senior nursing staff were able to overseetraining and ensure staff were completing their requiredcourses.

Learning and improvementThe department had a good approach to incidentreporting. We saw from our data the hospital was an activereporter of incidents when compared with other similarorganisations. We reviewed the incidents relating to A&Efrom November 2013 to 24 February 2014. The reportingwas varied and covered a range of incidents. It appearedopen and honest. The majority of incidents resulted in noharm to the patient. The earlier incidents in the report hadbeen analysed, actions taken were recorded, and theincident was closed. Some more serious incidents or thoseneeding the input of other teams or departments were onhold waiting final approval.

Systems, processes and practicesThere were adequate infection control processes andpractices. There were clearly indicated hand-washingfacilities in the department including hand sanitising gelplaced appropriately. Staff said they had enough personal




protective equipment including gloves and aprons. Nursingstaff 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). The department was clean,well-organised to help effective cleaning, and fixtures andfittings were maintained. We saw good practice in thechildren’s A&E department where a child with chicken poxwas cared for in a cubicle.

Where needed, areas of the department were locked andsecure. Medicines, equipment, and consumables were inlocked rooms or cabinets. Wheelchairs and trolleys wereable to move safely through the department as needed.

The layout of the department and adjacent facilities wasgood despite the capacity issues within the resuscitationarea. The x-ray department was located next to thedepartment and the computerised tomography (CT)scanner, which took 3-D images of the inside of the body,was also closely located. This equipment was used forpatients, for example, who had experienced a majortrauma. We met with the staff of this department who werepreparing for a trauma patient to arrive. They had advisedanother patient who was waiting for an elective(pre-arranged) scan they had to wait slightly longer thananticipated due to an emergency.

Monitoring safety and responding to riskStaff were supported to raise concerns without fear ofreprisals. Staff said they were encouraged to speak upabout any concerns. We read the hospital Trust’swhistle-blowing policy dated August 2013. This policyoutlined the duty of staff to report concerns, how theywould be dealt with, and the support available to staff whoraised concerns. The policy went on to describe the processfor managers who were dealing with complaints.

The staffing levels had improved and the department wasusually safely staffed. We spoke with staff from a widerange of disciplines about staffing levels. We saw somegood levels of recruitment to previously high vacancies inband five nurses. There was now a relatively low vacancyrate for nursing staff in the emergency department at 5%.Sickness rates at the hospital were, overall, below thenational average. Staff were joining regularly andinductions were underway. A senior member of the nursingteam said the lack of ability to recruit was, however,sometimes “soul destroying.” A recent recruitment drive forhealthcare assistants shortlisted 20 people and only three

turned up for interview. All the staff we talked with said thestaffing establishment levels (how many staff thedepartment needed) were generally good. But, as onemember of staff said: “we don’t shut the doors here andsometimes patients keep coming and then you have notgot enough staff or enough space either.” The nurse wenton to say they felt they saw patients in the priority neededmost of the time; they evaluated patients quickly; patientsgot good care; and most patients understood changingpriorities and that “staff are doing their best”.

The response to changes in the needs of patients in termsof staffing levels was good. A member of the senior stafftold us the hospital had a “really very good” system ofresponding and managing staffing levels when the hospitalwas under bed-space pressure. They said the model usedwas “excellent” at identifying risks in wards and units whenthe acuity or needs of patients changed. This enabledwards to send staff to help busier departments when theycould, and extra staff to be drafted in when needed. Themodel worked in real-time and enabled staff to quicklyrespond to emerging risks and triggers.

Bed-pressure meetings brought staff together to look ateach area’s capacity, but the actions were not proactive. Weattended a hospital bed meeting where the capacity acrossthe hospital was reviewed. A&E staff were present at thismeeting. Bed-pressure reports were collated at meetingsheld twice daily. In the bed meeting we attended, wherethere was a shortage of beds reported, there were no clearaction plans, or response to what the hospital was going todo about this capacity trigger, despite there being clearactions to take in the escalation policy.

The children’s emergency department was staffed by apaediatric trained nurse for the majority of the day. Thisenabled the service to deliver effective care and treatmentfor children. The Royal College of Paediatrics and ChildHealth (RCPCH) Standards for Children and Young Peoplein Emergency Care Settings (2012) identified there shouldbe always be registered children’s nurses in emergencydepartments, or trusts should be working towards this, andthat staff should, as a minimum, be trained in paediatric lifesupport.

The children’s emergency department was generally staffedby two trained nurses; one trained in the care of sickchildren and one general trained nurse with an interest incaring for sick children. One nurse started at 7:15am with asecond nurse starting at 10am. We were told there was




always a nurse trained in the care of sick children on dutybetween 10am and 6pm. We were told that at times thedepartment could be very busy with around 20 children. Atthese times the department may be allocated anadditional nurse. We were told when the department wasbusy this impacted on the nurses’ ability to give goodhigh-quality care. The nursing staff were supported by playspecialist four days a week which was said to help. At thetime of our inspection there were no nurses trained in thecare of sick children on duty overnight. The departmentwas being staffed by general trained nurses. Staff said therewere usually two nurses on at night with one being achildren’s nurse. We were told recruitment of nurses trainedto care for sick children was ongoing with an aim to recruitsix more nurses. The department was staffed by apaediatric specialist doctor with support from theconsultant of the week. The trust told us they hadundertaken a risk assessment of the situation and that theyfelt there was suitable cover and processes in place to gainsupport from the adult A&E staff and the paediatric servicein the children’s hospital.

In response to demand, and using winter pressure money,additional specialist registrars had been appointed to coverthe children’s emergency department. Further cover wasprovided by the consultant of the week.

Anticipation and planningThe department had plans to respond to major incidents oremergencies. There were plans held by senior staff to beimplemented in relation to different emergency scenarios.The hospital worked within a network of other local A&Edepartments and had back-up plans for transferring orredirecting patients to other units if the department orhospital needed to close or reduce arrivals in an unplannedemergency.

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 hip

fractures. 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 Excellent (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 used a standardabbreviated mental test to determine a patient’s memoryfunction or cognitive ability, often at triage. The documentused included other indicators which should trigger areferral to a doctor. This included the blood pressure range,oxygen saturation, and if there were multiple injuries.

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 nurse triage service where patients were seenas soon as possible after arrival. Notes were made for thedoctors about why the patient had come to the A&Edepartment along with some preliminary observations andsimple pain relief prescribed. There was also a recentlyintroduced Rapid Nurse Assessment (RNA) system, wheremore seriously unwell patients who presented at thehospital (referred to as “majors”) were quickly handed overto an emergency nurse practitioner by the ambulanceteam. We spoke with the Hospital Ambulance LiaisonOfficer (HALO) who provided a service to help facilitate themore rapid turnaround of ambulance crews andco-operative working. The HALO said their working in thedepartment that winter had meant the handover times hadbeen improved. The RNA system had also beeninstrumental in reducing the handover time of patientsfrom ambulance crews. The rapid assessment target for thenurse team was to carry out observations and any chestx-rays if needed within 15 minutes of arrival. We saw thatthis was happening most of the time.

Staff, equipment and facilitiesAlthough there were training programmes in place for staffin supporting people with cognitive impairment, staff saidthey had not had specific training in caring and supportingpeople with dementia or a learning disability. There was noautomatic screening for patients (unless they were over 75




years of age and to be admitted for more than 72 hours) todetermine if they had dementia or a learning disability andmay have additional needs. There was no evidence staffwere treating people with cognitive impairments withoutempathy and consideration, but they had not beenspecifically trained to recognise the signs and risks. We metthree staff who had come from a mental health facility withan unwell patient. They said experience of the departmenthad made them feel patients with a mental health illnesswere delayed due to the potential challenge theypresented. They felt staff had a good understanding ofmental capacity and assessments, but supported theconcern around staff not having had training in caring forpeople with cognitive impairment.

Support to nurses coming from overseas neededimprovement. One nurse who had joined the departmentfrom overseas two months ago said they were not sureabout what they could and could not do. They said theyhad been trained in their own country in a different skill setfrom the nurses in the UK and were expected to performtasks which they had not been trained to do. For example,the administration of intravenous drugs, which they hadnot been trained to do and their competency checked. Thenurse had a general corporate induction, but had not hadan induction into the department. Some training had beenprovided, but they said they did not feel adequatelysupported. Other staff in the department supported thisand said the department lacked a practice developmentnurse. We were told by a senior nurse this was needed“desperately” to support the significant recruitment of newstaff, many from overseas. The trust told us they had a twoweek development programme for new overseas nursingstaff in the emergency department which involved clinicalskills competency assessments.

The facilities in the children’s emergency departmentenabled effective treatment delivery of care for children.The Royal College of Paediatrics and Child Health (RCPCH)Standards for Children and Young People in EmergencyCare Settings (2012) states that there should be one ormore child-friendly clinical cubicle or trolley space per5,000 annual child attendances. Children should beprovided with waiting and treatment areas that are audio/visually separated from the potential stress caused by adultpatients. There was a dedicated children’s emergencydepartment within the main emergency department. Thishad seven bays/cubicles, a nurse assessment room, and awaiting/play area. One cubicle in the children’s emergency

department was set up and equipped as a resuscitationarea for very sick children. This was in addition to an area inthe main department’s resuscitation area, which was alsoequipped for children, though we were told that this spacewas usually used for adults.

Multidisciplinary working and supportMultidisciplinary working within the department was good.However, support from other departments for patientswithin the A&E was not always timely. Most staff said theyfelt supported by other departments and almost always bytheir colleagues in the A&E team. We were told by a seniornurse the trauma team were “pretty good”. On the day ofour inspection we saw that the plastic surgery departmentwere not attending the department in a timely way to helpwith patient care. There was an incident (as describedbelow) with a patient we met in the department and anincident recorded another delay of at least three hours inDecember 2013. The action plan said a new pathway hadbeen agreed with the plastic surgery team.

Are accident and emergency servicescaring?


Compassion, dignity and empathyObservations of staff showed that people were treated withcompassion and kindness in the department. Patientsconfirmed this. Although the response to the “Friends andFamily” test was low, the majority of patients said theywould be “extremely likely” or “likely” to recommend thedepartment to friends and family.

Some patients’ privacy was not respected or theirconfidentiality maintained. Most patients at thedepartment were assessed in private, but this did nothappen for patients being seen by the nurse triage team.The triage room was adjacent to the waiting room in theA&E department and was a corner room with windows anddoors on both sides. On both our visits the window blindsin the room were open and people outside the room in thewaiting area and corridor were able to see inside (althoughless so from the waiting room). The door was kept open onthe side facing the corridor and we could observe the nurseexamination and heard the discussion with the patient.When we briefly approached the room close to the doorwhere the conversation could be clearly overheard, no one




questioned our presence in listening to the conversation.We spoke with the patient who was being examinedafterwards and they said: “I’m really glad you witnessedthat and have told me who you are, but you could havebeen anyone. This seems normal around here, and has noone thought about it?” Staff agreed they had notconsidered the privacy and confidentiality for the patient,and accepted there could be some serious breaches ofdignity with some examinations or conversations. Theysaid they thought the blinds would be closed if necessaryand the door closed, but we saw the blinds were in a poorstate of repair and they would not have entirely obscuredthe room from outside. The “majors” area of thedepartment had recently introduced a system wherepatients who were able sat in chairs outside of bays whenthey were not being treated. The department recognisedthis had some issues for privacy and dignity but it hadmeant more patients were able to be treated andsignificantly improved ambulance crew handover times.

Involvement in care and decision makingPatients were involved in the care and taking decisionswhen they were able to be. One patient we met said theyhad been able to explain all their symptoms and answerand ask questions. They said nothing had been done orgiven to them without their consent. They said they did notfeel they were asked to do anything or follow a course ofaction without knowing why this was the best option forthem. They said they were given alternatives and the risksand benefits of all options. Staff knew the importance ofgaining valid informed consent for patients, and involvingthem in all decisions.

Trust and communicationPeople booking into reception in the waiting area could beoverheard. There were chairs in the area immediately infront of the glass screens of the reception area. The glassscreens did not require people to talk loudly as there weregaps in the glass, but people could be clearly overheard,particularly by people waiting in the chairs located close tothe reception desk. Four patients we spoke with in thewaiting room told us they did not mind giving their nameand address or date of birth, as they expected to do this.But none of them liked telling the reception staff what thereason for their attendance was, as they said this could beoverheard by others. One said they thought they couldhave withheld this reason if they chose to, but all thepatients said they felt they had to provide this information.One patient said: “I can see why this is important, but the

area does not exactly give you any privacy. Perhaps as thisis an A&E they think that doesn’t matter to us, but theycould have thought this out a lot better.” The reception staffsaid if a patient did not want to disclose why they hadcome to the department, they would write “personalproblem” in the notes and the triage nurse would discuss itwith the patient directly. The reception staff said they feltsafe in the department. They said the security team wereexcellent and there were always security staff on duty,including weekends and nights.

Patients were given some information about waiting times,but this was often difficult to manage. The system used bythe department was a manually updated display of theapproximate waiting time. When we arrived on thedepartment on Wednesday, the waiting room was almostempty. The waiting time was showing as three and a halfhours. One of the support staff said it needed to bechanged and it was amended to one hour. A patient wemet said they were about to leave the department beforethe waiting time was changed, as they were concernedabout leaving their unwell relative. When the time waschanged they decided to wait and were seen shortlyafterwards. One member of staff said the displayed timewas “a mixed blessing.” They said most patients wantedthis information and it was one of the questions mostasked of reception staff. However, the situation could andwould change very frequently in a department not able toanticipate activity. The member of staff said patients wouldthen want to know why they were waiting longer than theywere “promised” and this was often a source of patientsbeing abusive with staff. One patient we met said they hadbeen to the department before and the waiting time was“usually about right, and if anything, sometimes not as badas they say.” They said they had been required to waitmuch longer on one occasion, but staff had explainedabout the arrival of patients from a major road trafficaccident. They said patients were understanding andaccepted the change of priorities.

Some patients said they knew what was going on, butothers felt communication could be improved. One patientsaid they had been offered and given some pain relief whenthey had been seen by the triage nurse and were nowwaiting in the “minors” area for some test results. A relativeof the patient said: “Although I am sure this has been saidbefore, it’s really hard for patients when we see doctors andnurses sitting at work stations for long periods of time andno one seeming to do anything for [the patient].” They went




on to say: “I know about the four-hour target and I feelthings only start happening when that’s beginning toapproach.” Another patient in the “majors” area said: “Thecare here is very good. We were seen quickly and havebeen given a cup of tea.” The patient and their relative saidthey knew what was happening, what they were waiting for(admission to a ward) and staff had been “nothing buthelpful and kind”.

Emotional supportThere was emotional support to patients and theirrelatives. There were two relatives’ rooms in thedepartment. These had facilities for making drinks andcomfortable chairs. There were times in the busy A&Edepartment when relatives had to be excluded from areasfor the safety of themselves and the patient. Staff said theykept relatives informed, and relatives were permitted to bewith the patient if they were at the end of their life. Therewas a bay reserved in the “minors” treatment area fordeceased patients who were waiting to be taken to themortuary. This provided privacy for the patient and theirrelatives who were able to sit with them if they wanted to.The department was arranging for the room to berefurbished in order to make the environment less like acubicle.

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


Meeting people’s needsThe department did not have the capacity to meetpatients’ needs at all times. The A&E department at theJohn Radcliffe Hospital was part of the major traumanetwork in the South of England. This meant patients whohad suffered major injuries would attend a major A&Ecentre as long as it was no more than a 45-minute journeyby ambulance. Provision in the resuscitation room at thehospital was only for four patients at any one time (withone bed able to adapt to care for a child). Staff said theyhad been required to use the space for more patients whenthis was needed and “share” the equipment. The staff wemet said they did not know whether there was anyevidence captured to be able to say how often thishappened although we did see one incident report from

November 2013 about the capacity in the resuscitationroom being increased to six beds: two of these being in ashared space. There was no action plan recorded for thisincident. We reviewed the incidents for the last threemonths, and staff said they were sure this had happenedmore often in the last three months. An ambulance crew wespoke with said they were sure the resuscitation room wasfull “fairly often” and “it’s not really enough provision for ahospital this size”. When we were in the department onWednesday morning there were two patients in theresuscitation room. At around midday two more patientswere brought in by ambulance, one suffering a cardiacarrest. The beds were then fully occupied, including thebed set up for children, which was being used for an adult.Staff said if a fifth patient was to arrive at the samemoment, they would work out which bay they could use todouble-up care and treatment. Screens would be used, butthey had limited effect on privacy and dignity as staffneeded to share equipment and safely move around theroom and the patient. During this time all the nursing staffwere engaged with patients in the resuscitation room. Thisleft one healthcare assistant in the “majors” area with themedical staff and no other nursing cover at that time.

The department had an action card for staff to use forchanging circumstances in capacity of the department, butthe data around this was not being captured effectively todescribe pressures. The action card was clear about whatsituations were considered of higher risk. The triggers fortaking action were clear and straightforward. For example,the department would move to amber risk when there hadbeen more than 17 patients arriving per hour for two hours;or there were only two cubicles or four chairs available inthe “majors” area. Amber status would involve staff intaking actions such as considering extra resources andidentifying patients whose needs could be reprioritised.The triggers for red risk were, for example, more than 17patients arriving per hour for three hours; no availablecubicles in “majors”; and ambulances queuing. Actionswould include, for example, “minors” patients being keptinformed about delays and made aware of alternativeoptions; ensuring admitting teams of any patient waitingspeciality review having been contacted and escalating anyunsatisfactory responses to the operations manager forsupport. Staff were aware of the action cards, but there wasno evidence they were used alongside data tocommunicate the pressures in the department. A seniormember of staff said pressure scores were often not based




on empirical data linked to the escalation triggers. Thedepartment was using some of the data to communicate tostakeholders the pressures they were under. Staff said thewaiting time targets were calculated from actual data, butthe pressure scores were less actual data and more drivenby how staff were feeling. The department had an actioncard for staff to use for changing circumstances in capacityof the department, but the data around this was not beingcaptured effectively to describe pressures.

Patients said they were experiencing long waits to see adoctor. We spoke with seven patients in the waiting roomon the Wednesday morning and they all said they had seenthe triage nurse within 20 to 40 minutes. They all said theyhad no complaints about the treatment or care they hadreceived, but they all said there was a long wait to see thedoctor. A number of these patients had attended thedepartment before and most said there was always a longwait to see a doctor. One patient had attended “severaltimes” in the last year and said: “I think I might be lucky, butI don’t find the waiting times too bad.”

We saw many patients being well looked after when theywere in the main area of the department. However, at busytimes, some patients’ privacy and dignity was notmaintained. On two of our visits to the department,patients (on trolleys) were being placed in an atrium orcorridor at the front of the A&E entrance before moving to award or going home. This was reported as an incident bystaff. Staff were aware this was not ideal and were makingefforts to minimise the issues the situation was causing. Forexample, Heaters had been installed and screens wereerected when patients were waiting in this area. The doorsto the area at the ambulance-bay end were closed and aportable screen was in place at the other end of thecorridor. “No entry” signs were in place. Above this areawere windows looking directly down into the atrium, wherepatients could be seen. An incident report from January2014 reported a patient being kept in the atrium and beingcold due to the draft, despite being given “many blankets”.Staff were not able to provide a temperature managementblanket as there were no electrical sockets in this area.

One patient, who was in the atrium area waiting foradmission to a ward (they had been there for three hoursand in the department for eight hours) said the situationwas “dreadful”. “I feel a bit abandoned here.” They saidthere had been three other patients there in the time theyhad been waiting. They were helped to go to the toilet, and

had been offered a drink. They said the nursing care “hadbeen fantastic” but they were “really unhappy” about howlong they had been in the department and being in an areaotherwise designed as a corridor. They said they wereworried about being infectious to other patients or peopleas they had diarrhoea and vomiting. They were initially toldthey needed to be in a bit more isolation from otherpatients, but there was nowhere available.

There had been some changes made to improve pressurewithin the department. The trust had been supported bythe presence of GPs commissioned to work in thedepartment in the evenings and during the day onweekends. Other recent actions to improve patient flowthrough the hospital included:

Emergency admissions advisors recruited to take calls fromGPs and provide alternatives to admission to A&E. One ofthe three posts was still unfilled but the service was up andrunning.

A new care pathway developed to divert frail elderlypatients to identified wards.

Some additional bed space created in the EmergencyAdmissions Unit with further expansion planned for April2014.

The rapid nurse assessment model introduced to use theskills of experienced and qualified nursing staff to rapidlyassess patients as they arrived at the department.

An increase in consultant presence in the departmentimplemented in September 2013.

Establishment of an Urgent Care Group that met fortnightlyto review performance.

More porters were recruited to improve the service forpatient transfers.

Staff told us the portering service was not effective.Although reports said there had been more portering staffrecruited, staff said the service was “terrible” and “notworking”. A number of staff said this was, for them, one ofthe “things that could be solved so easily” but “causedsome of the biggest frustrations.” One member of staff saidthey often got “cross” with porters, but they were not reallyto blame for the situation.

Not all children had direct access at all times to theChildren’s emergency department but this did not impactnegatively upon their care and treatment. For example,




children who had sustained a minor injury could be seen inthe emergency department’s general minors' area due topressure upon capacity in the children’s emergencydepartment. On these occasions children would beassessed by a general trained nurse but paediatric trainednurses were available, if required, from the children’semergency department. Treatment was delivered in bayswith curtains so children were screened from care of adultpatients.

Vulnerable patients and capacityThere was a lack of awareness of the needs of vulnerablepeople in the department. During our visit on Sundayevening we were concerned about three children who wereunaccompanied in the waiting area. The staff on receptionwere not aware of the children and not able to see themclearly. We observed four members of nursing staff walkpast the children and not notice them or that they wereunaccompanied. When we asked the reception staff aboutthese children they did not offer a solution to providing anysupervision. One of the parents returned to the children 15minutes after we first became aware of them.

We observed a lack of support for a patient with dementia.We were aware of an elderly patient with dementia whowhen we first saw them at just after 9am had been in thedepartment for over eight hours. The patient was seenwalking around in a confused state, but being supportedwith kindness by a healthcare assistant. At around 9:30amwe heard the patient shouting from a curtained bay. Wefound the patient being restrained on a bed by his armsand legs by three security guards with the bed rails in place.The patient was restrained in this way for nine minutes. Wewere told the patient was to be seen by the plastic surgeryteam and they had requested the patient to be in a bed,despite there being an injury to their finger. The patient hadbeen given a sedative and was being restrained in order toawait the arrival of the plastic surgery team. We asked thenursing staff if there was a care plan put in place forpatients who had been subject to restraint. They told usthere was nothing they were aware of. They did not plan toassess the patient or document the restraint or report it asan incident. The nurse said they did not know if this wasdocumented by the security team. The nurse then askedthe patient if “anywhere hurt”. The person said their fingerand arms hurt. The nurse made a partial check of thepatient’s arms and legs. We saw the nurse then wrote somenotes in the patient record in retrospect at 11am. The notesdid not record the patient had been restrained. They

recorded: “patient’s wrists and legs are slightly red but noapparent bruising visible.” The patient was then moved to abed in the Emergency Assessment Unit (EAU) at 11:40amand the plastic surgery department had not yet reviewedthe patient. The handover to the EAU was done well andstaff were advised verbally about the use of restraint withthe patient. We had further discussions with the securityteam and they said they had been trained in control andrestraint. All three agreed they spent the majority of theirtime looking after and restraining confused patients orpatients with dementia. The trust told us the restraint hadbeen reported as an incident and investigated by thedirector of development and the estate and independentlyby the trust security manager between 26 February and 4March 2014. The recommendation from this investigationwas that there was no further action necessary.

The department used assessments to protect vulnerablepatients. These included an environmental risk assessmentfor patients known to be or identified as at risk fromself-harm, chronic, or acute confusion. Patients were givenmental capacity assessments to determine if they wereable to make decisions for themselves. Staff were able todescribe scenarios in which these would be used. Staffwere knowledgeable about acting in the patient’s bestinterests if the patient was not able to give valid consent.Staff would only proceed with a procedure to save aperson’s life, or with the input of other health and socialcare professionals and the people who spoke for thepatient.

Access to servicesThe pressure on bed space meant waiting times in A&Ewere often not meeting targets, and this impacted uponpatient care. The A&E department had regularly breachedthe Government’s four-hour waiting target for 95% ofpatients to be seen and discharged from the department(to home or a ward, for example). We requested evidencefrom the hospital trust on the data related to the JohnRadcliffe Hospital, as opposed to the whole trust. Evidencereceived from the trust for the year 2013 showed 7% ofchildren being treated in the paediatric A&E unit breachedthe four-hour waiting time target. Of the patients coming tothe adult department 10% breached the four-hour waitingtime target. There were particular problems in March, April,and December 2013 when the breaches in children’s A&E




were 10%, 13%, and 16% respectively. In March and April2013, there were 24% and 20% of all adult patientsbreaching the four-hour waiting thing target. In January2014 this figure was 15%.

The breakdown of the reasons for breaches have 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. The patients we meton our visits who had breached the target were eitherwaiting for a bed, or for a specialist review.

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 now gave patients a copy ofthe letter and a clear explanation of what they shouldexpect to happen next. We met two patients who weregoing home following treatment. They said they had beenoffered advice and information to take home with them.

Learning from experiences, concerns andcomplaintsThe department learned from some complaints andconcerns, but handled more practical concerns better thanother sorts. For example, we were told by the matron themajority of complaints recently had been in connectionwith patient property being lost; patients not gettinganything to drink while waiting; and poor communication.In response to the issue with property, for example, thedepartment had introduced a check on a patient’s propertyto the nurse checklist. A machine was provided to enablestaff to more easily give patients a hot drink. Other staffsaid they had heard the issues around communicationwere a common topic for complaints and they understoodthis. However, they did not feel there was anything doneabout this to really resolve the problem. One member ofthe senior nursing staff said: “I don’t think we really see itfrom the patient’s point and a lot of anxiety could bemanaged by just much more communication.”

Are accident and emergency serviceswell-led?

Good –––

Vision, strategy and risksThe Emergency Department (ED) was aware of its widerrisks. Risks were discussed at the monthly clinicalgovernance meetings. The existing risks were reviewed andnew risks were agreed to be added to the risk register.There was a comprehensive and clear action plan for theED. This identified areas of concern and actions to be takento address these concerns. The staff responsible for theactions were identified and a completion date was set.Progress against actions was reported. The action planlooked at the way the wider organisation affected the EDand problems were shared and addressed acrossdepartments to look for ways to tackle problems together.

Governance arrangementsThe ED had strong governance arrangements. The A&Edepartment at the John Radcliffe Hospital was part of thedirectorate covering emergency medicine for the wholetrust. Staff therefore met with the team that includedcolleagues from the Horton General Hospital emergencydepartment. Clinical governance meetings were held eachmonth. We reviewed the minutes from the January 2014meeting. The meeting was attended by seven consultantsin emergency medicine, one of the two matrons, aconsultant nurse, and seven other senior staff. 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. Any actions were assigned to amember of the team and these were updated at the nextmeeting.

Leadership and cultureMost staff said they felt well supported. A nurse we spokewith who had recently joined the department said theyteam worked well together and supported each other. Thematron for the department said they felt the trust boardwere aware of the pressures the department was under




and were “very supportive”. Doctors we spoke with saidthey felt supported by the leadership. Staff told us and weobserved there was strong and committed leadership andsupport from the senior staff, including the matron andsisters, the consultants, and the nursing staff team. Stafftold us they felt part of a team who cared for and supportedone another.

Patient experiences, staff involvement andengagementStaff were not always engaged with patient experiences. Amember of staff told us they did not feel staff were toldabout patient complaints. We were told it was not anagenda item on team meetings. They said this might havebeen in an effort to protect staff from complaints, but itmeant sometimes there would be changes made withoutany apparent reason or basis for the change. Other staff wetalked with said the department was often so busy, thismight be one of the areas they did not have time to be toldabout. Staff agreed that they wanted to be better informed.

The response rate to the Friends and Family test was poor.In December 2013, for example, the response rate was 2.6%and in November 2013 was only 1.5% (England average10.4%). Despite the low response rate, of the 75 responses

in December 2013, 67 people said they would be“extremely likely” or “likely” to recommend the departmentto their friends and family. Only two people said they wouldbe “unlikely” or “extremely unlikely” to recommend thedepartment. The only response rate above the Englandaverage was in June 2013 with 12.1%. Of the 351 responses,305 people said they would be “extremely likely” or “likely”to recommend the department to their friends and family.Only 13 people said they would be “unlikely” or “extremelyunlikely” to recommend the department.

Learning, improvement, innovation andsustainabilityStaff were aware of the issues in their department andresponded appropriately. Each fortnight staff from A&Eattended an urgent care meeting. We attended one ofthese meetings and found staff knowledgeable andinnovative in their approach to risks and safety. Thedevelopments and innovations in the last six months werediscussed along with their relative merits and effectiveness.Things that were working well were suggested for use inother departments. Lessons from those things not workingas well were discussed as well as suggestions for how toimprove them.




Safe Good –––

Effective Good –––

Caring Good –––

Responsive Good –––


Information about the serviceThe John Radcliffe Hospital has one acute medicalassessment unit and a further 13 medical wardsspecialising in providing frailty assessment and elderlycare, stroke care, gastroenterology/hepatology and cardiaccare. The cardiac care department includes a cardiaccatheter laboratory and a cardiology and cardiothoracicward. The hospital also provides a medical day ward toprovide care for patients with medical needs, but who donot require admission.

During our inspection, we visited the medical wards,including the stroke and elderly care wards. We also visitedthe medical admissions unit (MAU) and medical day ward.We talked with 25 patients, 11 relatives, and 56 staff,including nurses, doctors, consultants, therapists, andsupport staff. We observed care and treatment and lookedat care records. We received information from our listeningevents, focus groups, interviews, and comment cards. Weused this information to inform and direct the focus of ourinspection. Before our inspection, we reviewedperformance information from, and about, the trust.

Summary of findingsStaff provided a safe service to patients receivingmedical care. Systems were in place to report, respond,and monitor safety issues across all levels of medicalcare. Safe staffing levels had recently been reviewed andseveral medical wards had increased their staffing tosupport the needs of frail, elderly patients. Recruitmentof staff to medical wards had been successful and thehospital continued to recruit into vacancies.

Integrated care pathways for those patients who hadsuffered a stroke were in place and performance wasmonitored to improve the service being provided.Action plans were in place to ensure sufficientrehabilitation therapists were available to improvedpatient outcomes. Integrated care pathways forinpatients with diabetes were still being formalised. Inthe Trust diabetes affects 14.7% of adult inpatients. Thediabetes quality group was responsible for themonitoring and delivery of the “Think Glucose” projectto improve the quality of care.

Some patients had multiple health, social and/orpsychological needs which required the input of severalspecialist teams. The multidisciplinary teams in thedivision were well integrated and had a strongcollaborative approach to care. Care and treatment thatwas agreed and delivered was not always recorded. Awritten record was not always available to all parties toensure continuity of care.

Staff were caring. Patients and relatives told us theywere treated with dignity, compassion, and respect.Patients were involved in planning their treatment and

Medical care (including older people’s care)

Good –––


staff knew how to protect the rights of patients wholacked capacity to make decisions about theirtreatment. Efforts were made to ensure patients stayedin contact with friends and relatives. The hospital hadtaken account of relatives concerns and action planswere in place to improve communication between staffand relatives.

The hospital staff faced significant challenges whendischarging patients to community services. They wereworking with stakeholders to deliver the dischargeimprovement programme. Additional resources hadbeen made available to the medical wards to improveinternal and external discharge arrangements. Theseincluded the recruitment of discharge plannersresponsible for co-ordinating patients’ discharge.

The hospital’s supported discharge service enabledpatients who no longer needed the hospitalenvironment to be cared for at home while waiting forlocal authorities to set up care packages. Ward staff haddeveloped effective relationships with transport andcare providers to facilitate discharge.

The service was well-led. Clearly defined governancearrangements were in place in the division which led toimprovements in quality. Staff felt supported, valued,and proud to be part of the organisation. Opportunitieswere available for staff to develop their leadership skills.Patients and staff informed service delivery and theirviews were understood at trust board level.

Are medical care services safe?

Good –––

Safety and performanceSystems were in place to report, respond, and monitorsafety issues across all levels within medical care.

The hospital used the “safety thermometers” to measuretheir risk performance. The NHS Safety ThermometerReport 2012-2013 showed a fluctuating performance fornew pressure ulcers, falls, venous thromboembolism (VTE)and patients with catheter related urinary tract infections.We spoke with the acting divisional head of nursing andgovernance to understand this performance. They told usthat the division had improved the assessment of patientsfor VTE which resulted in a sudden decline in patientsdeveloping thrombosis. Pressure ulcers and falls remaineda concern for the division and action plans were in place toimprove the management of people at risk of falls andpressure ulcers. Work had also been done to ensure thatthe same fall was not recorded multiple times as anincident which had happened in the past.

The hospital had reviewed the management of urinary tractinfections in people with long-term catheters. This wasrecorded as a safety incident when infections were treatedwith antibiotics. The infection control team wasincorporating the management of incontinence and sepsiswith this review as their analysis showed that these riskswere linked and needed to be managed together.

The division produced a monthly safety report whichdescribed their safety performance. Data from incidentreporting, mortality, hospital acquired infections,complaints and audits were used to judge how safe thewards were. Wards displayed their individual performanceand staff were able to describe the areas that requiredimprovement.

Staff received training in health and safety and incidentreporting. Staff told us that they were familiar with theelectronic incident reporting system. They had beensupported by the ward sister to complete their first fewincident reports. The matron told us that staff wereconfident in reporting safety incidents and this was


Good –––


encouraged across the wards. Staff told us that they hadreceived a phone call from the occupational health teamfollowing incidents they reported to ensure that they hadnot been injured or if they required support.

Learning and improvementSafety incidents were investigated by the hospital so thatlessons could be learned to prevent similar incidents fromreoccurring. Following on from an investigation of a fallwith harm, the learning from the incident was shared withstaff on the medical wards. This was discussed at theAdams and Bedford wards team meeting on 6 January2014. As a result nurses were told to ask medical teams toreview confused patients. Plans were also in place to reviewpatients’ blood pressure medication as this could at timescause dizziness that could increase the risk of falling. Thewards were tasked with working closer with the Fall Safegroup and the link nurse for falls. A monthly fall learningsession was being provided to staff.

Following the investigation of grade 3 and 4 pressureulcers, a new pressure ulcer management policy wasintroduced. To prevent grade 1 and 2 pressure ulcers fromdeteriorating these were now also recorded and monitoredclosely. A new tissue viability nurse had been appointed tosupport the medical wards to manage pressure ulcerseffectively. Training in the new policy was provided to staff.

Investigations of incidents were monitored at the monthlyquality meeting to ensure that they were completed in atimely manner and learning shared.

Systems, processes and practicesRegular audits were undertaken to ensure that staffadhered to procedures to manage risks. To monitoradherence to infection control procedures, hand hygieneand cleaning audits were undertaken monthly and theresults displayed on the ward. Improvements had beenmade to the cleaning audit and on some wards this wascompleted three times a month. The wards were clean. Wesaw staff washing their hands and wearing aprons andgloves. The division monitored the level of hospitalacquired infections. Reported Clostridium Difficile andMRSA bacteremia were within expected limits. Eachreported case underwent an in-depth review, and werediscussed at the infection control committee.

Systems were in place to safely manage medicines. Thehospitals adherence to these procedures had beenassessed and the wards were awaiting the action plan. The

Adams and Bedford wards had discussed medicationconcerns during their January 2014 team meeting and staffwere instructed to ensure that they adhered to themedicine policy.

Staff vacancy rate, turnover and sickness absence weremonitored monthly. Many vacancies had recently beenfilled. Wards staff told us that they were able to maintainsafe staffing levels on wards now that that more staff hadbeen recruited.

Staff told us that they were familiar with the ward policies.They were available on the hospital’s internet and staffwere able to locate them quickly.

Monitoring safety and responding to riskTo safely meet the needs of frail and elderly patients on themedical wards the staff establishments (levels and skill mix)were reviewed in December 2013. The safer nursing caretool (SNCT) and the Royal College of Nursing’srecommended ratio of nurses to care support workers(65%:35%) were used to determine the appropriate levelsof staff and percentage of skill mix. Following this reviewstaffing levels on the stroke ward, Ward 5A and wards onlevel 7 were increased.

Green, amber, and red staffing levels were set for eachward. Risk management actions had been agreed whenstaffing levels fell to amber or red. We saw that amber andred staffing levels were discussed at the twice-daily bedmanagement meeting and action taken to address therisks. All the wards we visited were on green status. Duringour night visit an additional staff member had beenprovided over and above the green level to support the riskof one patient falling on Adams ward.

There was sufficient medical staffing on medical wards andareas. This was both during the day and out of hours (atnight and at weekends). There had been a review ofout-of-hours medical cover and within the medical divisionwhich resulted in a change in the medical cover provision,to ensure that only doctors working within this divisionprovided cover. Staff said they had no difficulties incontacting a doctor for support at any time. They said thenew cover system was good because it ensuredconsistency and that the doctors knew the patients as wellas the staff on the wards. The out-of-hours medical coverwas also in place for stroke patients with a primarythrombolysis emergency response clinician available on allshifts.


Good –––


The support patients required to manage the risks to theirhealth and welfare was assessed on admission andreviewed weekly or more often if required. Staff coulddescribe how they would support patients at risk of fallsand pressure ulcers in line with the hospital’s policy.Systems were in place to respond to deteriorating patients.Staff understood what action they needed to take and toldus that the response from the resuscitation team, intensivecare nurse, on-call doctors, and thrombolysis consultantswere good.

Staff understood their duty under the local safeguardingarrangements. Ward sisters provided examples ofDeprivation of Liberty Safeguard applications that hadbeen made in line with the principles of the MentalCapacity Act 2005.

Anticipation and planningIn planning the safer staffing levels for the medical wardsthe division took into account the past trend of 4% staffsickness and high turnover of band 5 nurses. Byanticipating this risk they ensured that a staffing level wasagreed that could maintain safety even when these risksoccurred.

The medical wards had contingency plans in place torespond to winter pressures as well as emergencies andmajor incident. The actions staff should take weredisplayed on the ward. The winter escalation plan hadrecently been reviewed on ward 7C and updated withcurrent telephone numbers and additional actions.Responses included working with local providers to ensurealternative care arrangements were available to patients ifrequired. Staff were familiar with the emergency plans.

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

Good –––

Using evidence-based guidanceThe hospital’s clinical audit, clinical governance, andoutcome review committees ensured that the division waskept informed of relevant legislation, guidelines, andquality standards. Each NICE (National Institute for Healthand Care Excellence) guideline relevant to the medical

division had a designated lead. They were responsible forassessing the division’s compliance with the relevantguideline and agreeing actions where improvements wererequired.

Integrated care pathways for those patients who hadsuffered a stroke were in place and performance wasmonitored to improve the service being provided. Thestroke operational group met monthly and ensured thatcompliance with the stroke guidelines and performancewas maintained. In December 2013 the group noted thatBarthel, daily living, and mobility assessments had to bereintroduced and a neuroradiology protocol was requiredto ensure compliance with the guidance. The group alsoreviewed three local guidelines which had been approvedby the clinical governance committee. These related to anew venous thromboembolism (VTE) assessment, the useof intravenous thrombolysis and acute stroke care.

Integrated care pathways for inpatients with diabetes werestill being formalised. In the Trust diabetes affects 14.7% ofadult inpatients (compared to a national prevalence of15.3%). The hospital told us that the care for inpatients withdiabetes required improvement following incidents of poordiabetes care. Diabetes risk summits were held in Octoberand December 2013 to address these concerns. A diabetesquality group was being set up at the time of ourinspection. This would be responsible for the monitoringand delivery of the “Think Glucose” project to improve thequality of care. The first meeting was planned for March2014 It was to be chaired by the deputy medical director.Actions included a business case to bring diabetesinpatient specialist nurses numbers in line with thenational average as well as early and comprehensivestandardised assessments.

Systems were in place to ensure that patients nutritionaland hydration needs were met. Patients were weighed andscreened for malnutrition using the malnutrition universalscreening tool (MUST) on admission and weekly. Strokepatients’ swallowing was assessed to ensure that nutritionand hydration was provided through an appropriate route.Where concerns were identified a referral to a dieticianand/or speech and language therapist was made.

Performance, monitoring and improvement ofoutcomesThe division took part in national clinical audits. TheSentinel Stroke National Audit Programme (SSNAP) aims to


Good –––


improve the quality of stroke care by auditing strokeservices against evidence based standards. The SSNAPperformance figures were published in 2012 and the trustperformed in the upper quartile.

The multidisciplinary stroke team had a goodunderstanding of the areas that required improvement andthe action plan implemented by the stroke operationalgroup. Performance against 10 patient outcomes wasmonitored on a monthly basis. The reasons why targetswere not met were analysed and actions put in place. Overthe three months prior to our inspection, performancefigures showed that a shortage in occupational, speechand language and physiotherapy staff was a concern. Thishad been discussed at the December 2013 steering groupmeeting and action was being taken to address the impactof this on patient outcomes.

The hospital commissioned an independent audit inDecember 2013 to review their safeguarding arrangementsfor adults and children against good practice andcompliance against their policy. The review report noted‘‘an assessment of significant assurance has been given.However, we have identified the scope to improve thecapacity of the safeguarding team’’. A business case hadbeen put forward to recruit additional safeguardingspecialists.

The medical division took part in research to improveclinical treatment. Oxford University's Stroke PreventionResearch unit had been awarded the Queen's AnniversaryPrize for Higher Education. Research carried out by the unitshowed the risk of major stroke in the first few hours anddays after a mini-stroke was much higher than previouslythought. The unit developed simple scores to identifyhigh-risk individuals and showed that urgent use of existingtreatments reduced the risk of major stroke by 80%. Thishighly effective strategy, including emergency clinics formini-stroke has been adopted nationally andinternationally.

Staff, equipment and facilitiesNursing staff were required to complete a programme ofmandatory training which included health and safety,infection prevention and control, medicine management,safeguarding and consent. Specialist training was providedto ensure staff could respond appropriately to patients’needs. This included swallowing screening for strokenurses. Foreign trained nurses confirmed that theyattended a competency bridging course and attending

English classes. Care support workers attended the caresupport worker academy and were supported by practicedevelopment nurses to meet their band 2 competencies.Student nurses praised the support provided by practicedevelopment nurses and the mentoring by nurses on theward. Ward sister development programmes were availableto facilitate leadership development.

An electronic training system had been introduced toenable staff to complete training online. Staff told us thatthis system was easy to manage and led to an increase instaff compliance with training requirements. Deficiencies instaff training in dementia were recognised in the NationalAudit of Dementia (2012). The hospital has addressed thisconcern by developing a dementia training programme fordoctors, medical student, nurses, and other ward staff.Most of the staff we spoke with confirmed that they hadcompleted this training.

Refresher training was offered to ensure staff’s practiceremained up to date. Ward staff were required to attendpressure ulcer refreshers in February and March 2014 toreceive training in the new pressure ulcer policy andreporting. Ward team meetings were held monthly and thiswas an opportunity to reinforce policy and practice. TheAdams and Bedford team meeting in January 2014reminded staff to be mindful of confidentiality and to checkmedication expiration dates.

Multidisciplinary working and supportStaff told us that they had good working relationship withlocal care and transport providers. The discharge loungesister had met with a transport provider to review theeffective use of transport. Delays had occurred due toincorrect vehicle requests. Following the meeting, trainingwas provided to staff to enable them to identify andrequest the appropriate transport. A matron told us theyhad met with local nursing homes to discuss ways toimprove communication and effective discharge forspecific patients.

Some patients had multiple health, social and/orpsychological needs which required the input of severalspecialist teams. Staff told us multidisciplinary teams in thedivision were well integrated and had a strongcollaborative approach to care. We attended the dailyhandover meeting on the stroke unit. This was attended by


Good –––


all members of the multidisciplinary team. Treatment, care,and discharge were collectively reviewed for all patients. Arelative’s request about a patient’s treatment wasdiscussed and a plan agreed to address their concerns.

Handovers between shifts were detailed and staff told usthey understood the outcomes that were agreed forpatients. Care and treatment that was agreed anddelivered were not always recorded so that a written recordwas available to all parties to ensure continuity of care.Where dieticians required nutritional intake to bemonitored we found that fluid and food charts had notalways been completed. Physiotherapy plans were onroom walls but records did not indicate whether staff hadmobilized patients as requested or how long they had beenimmobile. Staff could describe the care provided topatients. However, mouth care, washing and dressing,mobility, and continence care plans were not seen forpeople who could not direct staff. Best interest decisionstaken by staff for people who lacked capacity and hourlypatient welfare checks had not always been recorded. Wewere told a working party had been set up to review wardpaperwork to ensure that it provided sufficient information.The "Knowing Me, Knowing You” document was also beentrialled to support people with dementia.

Are medical care services caring?

Good –––

Compassion, dignity and empathyWe observed and patients told us they were treated withdignity, respect, and compassion by all staff. Patients’privacy was respected and we observed curtains pulledwhen care was given. Call bells were to hand andresponded to in a timely manner. Patients were clean anddressed in their own clothes. We observed an evening mealon Adams ward for the elderly and saw that patients weresupported to eat at their own pace. Some patients couldnot remember what they had chosen to eat. A nursecomforted a patient, showing them the meal they orderedand reassured them that they could have something else ifthey did not like their meal.

Staff showed concern for patients’ wellbeing when theyreturned home from hospital. Patients on the dischargelounge were provided with a meal to take home if theylived on their own. Landlords were contacted to ensure

that heating was switch on before patients went home. Theward sister told us ”we have put in a request for some tracksuits so that people do not have to go home in thinpyjamas which is not dignified or warm”.

We received many positive comments which included: ”theward is a vibrant friendly place”, ”they [the staff] are verykind and tender with my father” and ”everyone – thehousekeeper, cleaners and nurses – all greet me by nameand always ask me how I am”.

Relatives of elderly patients told us at our listening eventand through "Your Experience” feedback that they were notalways satisfied with the care their elderly relativesreceived. They felt that patients waited too long to behelped and at times patients were not treated withpatience. Though we did not identify these concerns duringour visits to the wards we asked staff about this. Staff at alllevels, including the acting divisional head of nursing andgovernance, were aware that concerns had been raised.They told us action plans were in place to address relatives’concerns as disrespectful behaviour would not betolerated. Additional staffing had been provided on somemedical wards to ensure that staff could respond topeople’s needs in a timely manner.

Involvement in care and decision makingInformation leaflets about a variety of medical conditionsand treatment options were available to patients andrelatives to support them to plan their treatment. Leafletswere available in several languages, large print, Braille, oraudio. Patients could also request a language or Britishsign language interpreter. Picture symbol cards wereavailable on the stroke ward to support patients tocommunicate. Records showed that these had been usedby the physiotherapist to gain the views of patients.Oxfordshire advocacy service could support people wholacked capacity to make decisions about their treatment.

Information about dementia treatment and support wasavailable to relatives, carers, and patients. We attended themonthly dementia café. This is a drop-in informationsession held in partnership with local dementia servicesincluding Age UK and the Alzheimer’s Society. A consultantlead memory clinic was held every Thursday. The dementiacare advisor also met with patients and relatives at theclinic to provide information about support and treatment.

Patients and relatives told us they felt involved in thedecisions about treatment. They felt discharge


Good –––


arrangements were not always clear. Relatives had contactwith doctors, at the patients’ request, to discuss treatment.When speaking with doctors, they were provided with clearinformation and understood what the treatment optionswere. One person told us ‘‘it has not always been easy toget hold of the right person that could provide an update’’.Records showed that relatives and care home staff hadbeen actively involved in patients’ discharge planning inWards 7C and 7D, where the new discharge planners hadbeen recruited. The matron told us that discharge plannerswould be working across all medical wards once they werefully recruited.

Relatives were given the opportunity to be involved inpatients’ care. They were welcome to support patients withtheir meals and we observed this taking place. A relativehad expressed the desire to support with a patient’spercutaneous endoscopic gastrostomy (PEG) feeding ondischarge. Records showed that the dietician had involvedthe relative in planning the suitable feeding times. Traininghad been provided to ensure that the relative couldundertake this task competently.

Trust and communicationPatients and their relatives described staff as kind andcaring. They had high praise for the caring attitude ofhousekeeping and cleaning staff. Patients told us they feltsafe. We saw that the wards were busy. Patients told usstaff were supportive and took the time to talk to them,within the available time constraints. The acting divisionalhead of nursing and governance told us that they werespending time with patients and relatives in the evenings togain a better understanding of people’s needs for effectivecommunication. They would be establishing regularmatron or consultant meeting opportunities for relatives tosupport the development of open, trusting relationships.

Patient confidentiality was respected. We observedpersonal conversations taking place in private and did notoverhear staff discussing patients. Records showed thatpatients had been asked to give their permission to havetheir names on the ward boards. We saw that patients’names were removed swiftly as they left the dischargelounge.

Emotional supportPatients were supported to stay in contact with family andfriends. Visiting times were flexible and relatives of elderlypatients were welcome to spend long periods withpatients. We observed staff supporting patients to make

and received phone calls. Adams and Bedford ward had acommunal area where patients could sit to preventisolation as all the rooms were single rooms. Two patientstold us that they felt lonely at times being on their own in aroom. We observed staff going into patients’ rooms tomake conversation as well as engaging with patients whosought their company.

The registrar on the elderly wards told us ‘‘we supportpatients and their families when a diagnosis of dementia isshared as this can be an emotional time for everyone’’. Wespoke with psychiatrists in this team and they confirmedthat they met with relatives and patients that might requireemotional support to manage their diagnoses or condition.They also provided ward staff with guidance in how to meetthe emotional needs of patients with dementia.

Chaplains were available to meet with, to be with, to listenor to talk through with patients and their families theirconcerns and anxieties. NHS chaplains from the Christian,Islamic, and Hindu faith traditions provided a 24-houron-call service to all patients, relatives and staff, whether ornot they have a religious faith.

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

Good –––

Meeting people’s needsThe hospital worked with stakeholders to plan and designservices to meet the needs of the local community. Thesepartners included Oxford County Council, Oxford ClinicalCommissioning Group (OCCG), and Oxford Health. TheOCCG noted that the group “regularly holds meetings todiscuss quality and clinical governance arrangements withthe OUH. This meeting is attended by senior clinicians andmanagers. This has started an open dialogue between thetwo organisations to discuss the challenges faced withinthe Oxfordshire health economy.’’

There were co-ordinated pathways of care agreed withpartners to meet patients’ needs. The hospital was part ofthe Oxfordshire dementia development andimplementation board which was tasked withimplementing the National Dementia Strategy locally. Theboard met quarterly and the hospital’s dementia steering


Good –––


group led on improving care of patients with dementia.Staff told us that the medical division had some actionsfrom the steering group. These included staff undergoingtraining in dementia care and we saw that each ward had anamed dementia champion. The hospital had beenrewarded grant funding to create a dementia friendlyenvironment for patients on level 7 and work was to start inMarch 2014. The hospital agreed to routinely undertakememory screening of patients over the age of 75 to ensurethe identification and referral of patients with dementia.

The hospital planned services to meet the needs ofpatients with mental health needs. An integratedpsychological medicine service had been established tobetter meet the needs of this patient group. Consultantsfrom this service worked as part of medical teams to delivermental health input to patients on medical wards. As wellas assessing and treating patients, the service providededucation and support to enhance the psychological caregiven to all patients by doctors and nurses. Psychiatristsworking in the team told us that this service enabled thehospital to respond to patients with mental health needsswiftly while they are treated in acute medical wards. Onepsychiatrist told us ‘‘patients don’t have to wait till theyleave hospital to access mental health services and we canrefer people more effectively to community services ondischarge’’.

Vulnerable patients and capacityPatients who lacked the mental capacity to make adecision were supported in line with the principles of theMental Capacity Act 2005 (MCA). Staff received training inthe safeguarding of vulnerable adults and showed a goodunderstanding of the MCA and Deprivation of LibertySafeguards (DOLS). Ward sisters were responsible forcompleting DOLS applications and told us that thepsychological medicine service provided guidance forcomplex applications. One patient had a representativethat held the legal power to make decisions about theirhealth and welfare. Staff understood the implications ofthis and explained what action they had taken to ensurethe legal representative was involved in any decisionsabout this patient’s care. A specialist learning disabilitynurse was available to support people with learningdisabilities.

Patients who might have fluctuating capacity weresupported to manage their confusion. Patients werereassured and helped to cope in the hospital environment

so that they could better engage in decision making. Effortswere made to ensure that the impact of a patient’sconfusion on other patients was minimized. Staff told usthat the single-room accommodation on Adams andBedford wards were prioritised for dementia patients thatneeded a quiet environment. Patients who required regularreassurance were also given rooms close to the nurses’station so that they could be responded to swiftly. A nursetold us following input from the psychological medicineservice one patient was moved further from the nurse’sstation as it was felt that this person required less noiseand activity around them to manage their confusion. Theytold us that this had worked well for this patient.

Records showed that a patient with communicationdifficulties had been supported to express their consentabout having a PEG procedure. Nurses were not alwaysclear who would support people with communicationdifficulties to make significant decisions, especially if aspeech and language therapist was not available.

Confused patients at risk of falling had been assessed asneeding low beds and bed rails to keep them safe when inbed. Nurses could describe the action taken to accessthese patients’ capacity and how best interest decisionswere made where patients had lacked capacity. Recordsshowed that this process for gaining consent for the use ofrestrictive equipment had not been recorded. We were toldthat a new bedrail consent form was being developed toensure consent was appropriately sought.

Access to servicesSeveral initiatives were being piloted to ensure elderlypatients and those with long term conditions could accesscare closer to home. These included stroke rehabilitationservices in Abingdon and Witney. A joint team was alsoestablished with Oxford Health NHS and OxfordshireCounty Council to speed up and rapidly implementdecisions on patient discharge. Four Emergency MedicalUnits (EMUS) had also been created in partnership withGP’s in Abingdon, Banbury, Witney, and Oxford.

The hospital was sensitive to the support patients, whowere in vulnerable circumstances, might require to accessservices. An equality impact analysis was undertaken foreach care and treatment protocol. The equality impactanalysis for the pressure ulcer prevention guideline notedthat patients with learning disabilities and those who donot speak English ‘‘might need additional assistance andadjustments to enhance communication while in hospital’’.


Good –––


We saw that telephone and face-to-face interpreters wereavailable. One family told us that they had declined aninterpreter and preferred to interpret for their father. A textphone service was available to support deaf, hard ofhearing and speech-impaired patients to makeappointments. Patient transport could be arranged forpatients’ with disabilities.

The hospital anticipated that there would be a higherdemand for medical beds during the winter. Fourescalation beds were available in the Adams ward toensure that medical patients could be treated on anappropriate ward. These beds had been filled for somemonths and staffing on the ward had been adjusted tomanage with this increase. We attended the hospital’s bedmanagement meeting which was held twice a day.Anticipated admissions and discharges were monitoredduring the meeting to facilitate the flow of patients throughthe hospital. Due to a lack in bed capacity one medicalpatient had been admitted to a surgical ward. Plans were inplace for them to be moved to an appropriate ward later inthe day. We spoke with the clinical director for acutemedicine and rehabilitation who told us that there was ahigh demand for beds across the hospital. They explainedthat the medical division had improved the managementof its bed occupancy over the past 18 months. Fewermedical patients were admitted to other divisions andpatients were primarily moved between wards for clinicalreasons. Medical patients were assigned to a namedconsultant responsible for their care from admission. Thismeant if medical patients were admitted to other specialistwards they could be reassured that they would receiveappropriate clinical input.

Patients on the stroke ward did not always have timely orongoing access to speech and language or physiotherapy.We did not find that this resulted in unsafe care but meantthat some patient’s recovery or discharge could have beendelayed.

Leaving hospitalManagement, staff, patients, and relatives told us therewere delays in discharging patients from hospital. Severalpatients on the medical wards were ready to bedischarged. The majority of delayed discharges were due topatients waiting for appropriate community care services.The hospital was working with stakeholders to deliver thedischarge improvement programme. Additional resourceshad been made available to the medical division to

improve internal and external discharge arrangements.This included the recruitment of discharge planners onmedical wards responsible for coordinating patients’discharge. Discharge planners had started working onWards 7C and 7D. Records showed that they plannedpatients’ discharge from admission, ensured all relevantinformation was shared with social services and liaisedwith care agencies, and arranged transport. Attempts weremade to discharge patients to community services close tohome. This had not always been possible and patientsrefused these discharge arrangements if it did not meettheir needs.

Some patients required care and rehabilitation at homeonce they were discharged. The trust’s SupportedDischarge Service supported people for the first six weekstill a care package was in place. People who no longerneeded the hospital environment could be cared for athome while waiting for their care packages. Nurses hadhigh praise for this service.

Discharge support workers had been recruited to supportpatients from wards to the transfer lounge. They ensuredpatients were dressed appropriately, provided assistancewith personal care, and collected patients’ take homemedicine. Patients with dementia were transferred homefrom their ward to minimize disruption and confusion.Patients in the transfer lounge told us the wait could belong but that they were well looked after while they waitedfor their medication or transport. Actions were in place toimprove the processing of medication for discharge.

The transfer lounge sister told us that the ward had goodworking relationships with care and transport providers.Nurses had been given training to identify the correctspecialist transport required to take patients home. TheSouth Central Ambulance Service liaison officer had beenbased on level 4 from January 2014 to help facilitatetransport.

A weekly multi-agency discharge meeting took place.During this meeting all the patients reviewed by theDischarge Pathways team were monitored to ensure thatappropriate arrangements were in place to meet patients’needs following discharge. The hospital audits out-of-hoursdischarges, and overnight discharges remain low at 0.6% ofpatients.


Good –––


Patients and carers had been involved in designing the newpatient leaflets for discharge. Several leaflets were availableto patients providing information about how to plan for thedischarge process, transport and information aboutmedicines.

Learning from experiences, concerns andcomplaintsThe medical division captured patient feedback. Thisincluded results from the “Friends and Family test”,complaints and comments, Patient Advice and LiaisonService (PALS), Healthwatch Oxfordshire, National InpatientSurvey and Patients Stories. Adams ward had a low Friendsand Family Test response rate in November 2013. Effortshad been made to improve the completion of the friendsand family test by asking all staff including housekeeping toremind patients and relatives to complete the form. InJanuary 2014 Adams ward aimed to achieve a 20%response rate. 24% was achieved with 100% ofrespondents saying that they were likely to recommend theward to family and friends. Results of the friends and familytest were displayed on wards.

Patient feedback was reviewed at monthly divisionalmeetings. Two patient stories relating to diabetes carewere presented at trust board and quality committeemeetings in February 2014. Lessons learnt from thesepatients’ experiences were captured in an action planwhich included training for staff in adhering to diabetesprotocols and supporting patients to manage their anxiety.The acting divisional head of nursing and governance toldus and staff confirmed that patients and relatives primarilyraised concerns about communication, not receivingappropriate assistance and discharge on the medicalwards. Actions were in place to address these concerns andto gain a better understanding of how concerns could beaddressed swiftly on the ward.

We spoke with the sister in charge of the discharge loungeto see what action had been taken following theinvestigation of two complaints. Changes had been madeto the cleaning of the floor to ensure that it did not pose aslip risk. Systems had been put in place to monitorpatients’ deterioration while waiting in the transfer lounge.Transfers would be halted by the discharge staff if theyassessed patients were unfit for transfer.

Leaflets and signs were on wards to inform patients how tomake a complaint, access PALS, and complete the “Friendsand Family test”. Patients could access the IndependentComplaints Advocacy Service (ICAS) if they requiredsupport with making a complaint.

An example of the division’s complaints and action takenwere published in the hospital’s annual Quality Account.

Are medical care services well-led?

Good –––

Vision, strategy and risksThe hospital told us they were committed to ‘‘DeliveringCompassionate Excellence’’. They described the cultureand values underpinning the hospital as ‘‘learning, respect,delivery, excellence, compassion and improvement.’’ Wespoke with staff from all levels in the division. They wereproud to be part of the hospital and passionately sharedthe vision. Staff consistently told us that it was theirprimary concern to ensure that the patients they cared forwere treated with respect and compassion. Theinformation noting the vision of the hospital was displayedthroughout the hospital and wards to invite staff andpatients to become involved in shaping future plans.

Systems were in place to ensure that risks were identifiedand understood on all levels. The concerns regardingrecruitment and discharge shared by staff on the ward werethe same as those captured at division and board level.

Governance arrangementsClearly defined governance arrangements were in place inthe division. Sisters and matrons were clear what theirresponsibility were in analysing and reporting on qualityinformation. Records showed that their information wereused to inform the division’s monthly quality meeting andthe hospital-wide clinical governance committee. Clinicalgovernance was integrated across divisions. Risks relatingto pressure ulcers and falls were assessed across thehospital. Meeting minutes showed that high qualityinformation, from several sources, were presented to theclinical governance committee and board to inform theirdecision making. We saw that the board had requestedclarification of information on several occasions includinghow the safer staffing levels in the medical wards had beendetermined. A detailed response had been provided.


Good –––


The hospital monitored risks to the delivery of care througha risk register. The medical division’s risks included the riskof not maintaining safe staffing levels as well as delayeddischarges. The clinical director for acute medicine andrehabilitation owned this risk. We spoke with them andthey explained what their responsibilities were in managingthis risk. They understood the cause, effect, and impact ofthis risk as described in the risk register.

Leadership and cultureThe hospital has a clear leadership development strategydeveloped in consultation with the workforce committeeand medical division. Opportunities were available todevelop leadership capabilities to solve problems,innovate, and manage change. Many staff had leadresponsibilities for enhancing patient pathways on themedical wards. This included dementia, falls, consent andsafeguarding champions. The sisters developmentprogramme and the new consultant developmentprogramme was available to staff. We spoke with a newconsultant who told us that they had experienced strongleadership since being part of the division and had beenencouraged to build co-operative relationships across thehospital. Human Resources’ practices promoted a cultureof compassion towards patients. The hospital usedvalues-based interviewing to ensure that staff wererecruited that prioritised high quality and compassionatecare. A sister explained to us how this had beenimplemented in the recent recruitment of Spanish nursesto medical wards. The matron explained how the hospitalsvalues had been incorporated in the clinical supportworkers academy as well as the competency bridgingcourse for foreign workers.

Staff were complimentary of the managers and leaders.They told us they felt valued and supported. Staff wereencouraged to take breaks to promote their wellbeing atwork. A second annual staff recognition awards ceremonywas held in November 2013. Staff who attended told usthey appreciated that performance in compassionate carehad also been acknowledged. Staff told us that they hadreceived an annual appraisal. They were clear what theirpersonal and professional development plan was followingtheir appraisal. The matron told us that a new electronic

learning management appraisal system (ELMAS) had beenintroduced and several appraisals were still due. The sisteron the discharge lounge explained how they had used thisto record their staff appraisals.

Patient experiences, staff involvement andengagementStaff and patient feedback is an agenda item at monthlygovernance and board meetings. All whistle-blowingconcerns raised regarding clinical quality has to be sharedwith the clinical governance committee to ensure thataction was taken to address these concerns. Results fromthe “Friends and Family test”, complaints, compliments,and PALS contact were monitored at the division’s monthlyquality meeting. There was a shared understanding thatpatients and relatives concerns on the medical wards relateto communication, delayed discharge, and not alwaysreceiving the appropriate support at the right time. Actionplans were in place to improve practice and patientsexperience. Positive feedback received from patients andrelatives were displayed in wards and celebrated by staff.

The hospital continued to embed the Listening into Action(LiA) project. This empowered staff to find innovativesolutions to problems they identified. The medical wardswere identifying their LiA champions.

Learning, improvement, innovation andsustainabilityRisk reporting systems were reviewed to ensure that theyprovided information that could improve performance. Wespoke with the acting divisional head of nursing andgovernance who explained that work was underway todevelop an innovative integrated risk reporting system. Thisrisk information would follow patients through their carepathways and provide a comprehensive understanding ofrisk over time.

The board took time to review and improve performance. Aboard away day and seminar programme were held inOctober 2013. This day focused on understanding thechallenges faced by medical wards to ensure safe staffing isprovided to care for frail, elderly patients. Budgetmanagement was explored to ensure that budgetadjustments were made to incorporate the increasedstaffing levels.


Good –––


Safe Requires Improvement –––




Well-led Requires Improvement –––

Information about the serviceThe John Radcliffe Hospital provided a range of generaland specialist surgery, including trauma, vascular, cardiac,spinal, ophthalmic, neurosurgery, plastic surgery, ear noseand throat (ENT) and general surgery. Services weremanaged within five clinical services divisions.

We visited two trauma wards, a neurosurgery ward, and thesurgical emergency unit. We also visited theatres in themain hospital and in the west wing.

We talked with 19 patients, four relatives, and 26 membersof staff. These included all grades of nursing staff,healthcare assistants, domestic staff, consultant surgeons,consultant anaesthetists, junior doctors, and seniormanagement. 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 findingsThere was consensus among patients, carers, and staffthat staff were dedicated and provided compassionate,empathic care. However, there was frustrationexpressed by many staff at all levels that they were notalways able to provide safe and effective care. This wasdue to a lack of capacity, brought about by insufficientresources and work flow.

Pressures within the wider health economy presentedsignificant challenges in terms of demand versuscapacity. There was evidence that the hospital wasworking with other partners to respond to this butpressures were compounded by significant andon-going staff shortage and management of resources.

There was an overwhelming sense of discontentexpressed by some senior clinicians, who felt the trustboard was motivated by financial, rather than by clinicalmotives. This was at odds with the one of the statedvalues of the trust; “putting patients at the heart ofeverything we do”. We saw evidence of strong clinicalleadership at a local level but senior clinicians feltdisempowered and believed they had no voice. We sawevidence of good team working at ward anddepartmental level but there was silo working acrosssites and divisions within surgery.

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Are surgery services safe?


Safety and performanceThere were 206 patient safety incidents (trust-wide)reported by surgical services to the National Reporting andLearning System (NRLS) between July 2012 and July 2013,accounting for 34% of all incidents reported across allspecialties. Of these, 192 were categorised moderate, 11abuse, two severe and one death. These were withinstatistically acceptable limits for all notifications.

Risks to patients identified by the NHS Safety Thermometerwere being managed. Records showed that national safetyguidance was followed on the prevention andmanagement of pressure sores, blood clots, falls andcatheter urinary tract infections on surgical wards. Therewere systems in place to ensure that patients’ nutritionaland hydration needs were identified and met and that theywere supported to eat and drink.

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. A never event is classified as such because itis so serious that it should never happen. One of thesenever events was a surgical error which occurred in thewest wing theatres at the John Radcliffe Hospital. A wrongpower lens was implanted into a patient’s eye.

Hospital mortality data showed that mortality rates insurgery at this hospital were not a cause for concern. Theincidence of pressure ulcers, infections, venousthromboembolism (VTE), and falls on surgical wards wasalso within the expected range.

Staff were aware of their responsibility and the process toreport untoward incidents but there was inconsistency interms of their understanding of reporting thresholds. Therewas under reporting of incidents. Some staff told us theydid not report incidents because they did not have time;others felt it was a pointless exercise because “nothingwould change”. We asked three staff if they would reportthat a theatre list was not supported by the recommended

number of staff. They all told us they would not. Staff on theneurosurgery ward told us planned operations werefrequently cancelled due to emergency demand. They saidthese cancellations were not captured as incidents.

One staff member told us the trauma ward they worked onwas “purpose built and fit for purpose”. Bays and singlerooms were spacious and allowed safe moving andhandling of patients. The wards were well equipped withlifting equipment and there was ample storage. There wereappropriate “anti-slip” floor finishes and hand rails toprevent falls. There were call bells in bathrooms and toiletsso that people could call for help.

Concerns were expressed by staff, including senior staff andmanagers, about the condition of the premises in the maintheatres. The trust’s risk register recorded: “Cardiactheatres require complete refurbishment: Potential risk ofinfection as inadequate space to walk patient around whenequipment laid out.” The register recorded that there was“robust site surveillance” in place to mitigate this risk andthere were plans to refurbish the main theatres, with workdue to commence in April 2014.

There were concerns expressed by staff that trauma andspinal surgery was taking place in theatres without alaminar flow air system. This system is recommended toreduce the risks of wound infection in certain types oforthopaedic surgery. These concerns were not listed in thedepartment’s risk register but the general manager wasaware of the concerns, which would be addressed by theprovision of new theatres. The number of surgical siteinfections in the orthopaedic directorate from November2012 to December 2013 ranged from nil to four per month,with the highest rate of four being recorded during themonths of September, October and November 2013.

Staff told us that patients’ operations were sometimescancelled due to lack of capacity. Capacity was affected bylack of theatre space, suitability of premises, availability ofsuitable equipment and appropriately trained and skilledstaff. Concerns were also expressed about efficiency. Thesame day cancellation rates for specialist surgery wereshowing an upward trend, with 4% cancelled in October2013.

Learning and improvementOn surgical wards we saw information displayed aboutareas of risk, such as the incidence of pressure ulcers andfalls. Staff, patients, and visitors were able to see how they

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were performing in these areas. They told us that incidentswere discussed at regular ward meetings and teachingsessions had been provided by, for example, tissue viabilityspecialists. In theatres however, staff were less wellinformed. Departmental governance meetings had notbeen taking place due to staff shortages.

We saw little evidence that staff were aware of or had learntfrom serious untoward incidents, including never events.Three theatre nurses we spoke with had no knowledge ofnever events or serious incidents occurring in theatres.

An investigation report (December 2013), following a neverevent in ophthalmic surgery in August 2013, noted that asimilar event (not classified as a never event) had occurredin the same clinical service in May 2013. A root causeinvestigation at that time had recommended a change inpractice. However, when the second event occurred it wasfound that this new practice had not been followed. Thereport concluded that the recommendations had not beenwidely circulated. It was also found that there had beeninadequate discussion by the operating team as part of theWHO safety checklist process so that there was a collectiveunderstanding of the lens to be implanted. The WHO safetychecklist was developed by the World Health Organization,and requires all of the theatre team to engage and acceptjoint responsibility for ensuring that safety checks areundertaken at each defined stage of the surgicalprocedure, thereby minimising the risk of the mostcommon and avoidable errors occurring. It was noted thatthe culture in the theatre at the time of the incident wassuch that staff did not feel able to speak up if they feltconcerned.

An action plan committed to review the checking systems,to provide “human factors” training to the ophthalmologytheatre team and to disseminate learning from the event toall staff working in similar areas in the trust. The action planhad not been updated to show progress against theseactions. However, we were told by the general managerthat “human factors” training had commenced for theatrestaff. Human factors training examines the factors that caninfluence people’s behaviour at work.

A serious incident had taken place at the NuffieldOrthopaedic Centre in March 2013, which had resulted inthe death of a diabetic patient following surgery. Theinvestigation into this event had recommended thedevelopment of a protocol for the perioperativemanagement of diabetic patients so that staff understood

when they should seek intervention in relation to patients’blood glucose monitoring. On the neurosurgery ward wesaw a diabetic patient who had repeated low bloodglucose readings. The nurse caring for this patient had noguidance as to what action to take in the event of high orlow readings. They told us they thought there was aprotocol on the trust’s intranet but they had “no time to goon-line”. They were also unaware if there was a policy onthe administration of insulin. We were concerned thatalthough learning had been identified through theinvestigation and subsequent risk summits in the trustfollowing this serious incident, the process ofdisseminating this to staff was not effective. This placeddiabetic patients at risk of receiving poor or unsafe care.

Systems, processes and practicesThere were systems and processes in place to keep peoplesafe. We observed a theatre team participating in a teambrief/planning meeting prior to their operating list starting.They introduced themselves, discussed the plannedtheatre list and equipment. We witnessed them engagingwell with the WHO checklist process. Checklists had beenadapted for some specialties. One staff member told usthat compliance with this safety tool was “getting better”,although they said some staff found it difficult to assertthemselves and sometimes the “sign out” section of theprocess (before the patient leaves the operating theatre)was not completed. They said this was because some stafffelt intimidated by some surgeons who did not allow themtime to do this. This suggested that a culture change intheatres was still required. Monthly audits of WHO checklistcompletion took place. Performance in the neurosciences,orthopaedics, trauma and specialist surgery rangedbetween 93% and 100% in the period November 2012 toDecember 2013.

There were procedures in place for close monitoring ofpatients immediately following surgery, with observationcharts being completed hourly for four hours and reducingincrementally thereafter. A “track and trigger” process wasused to monitor patients’ important signs, such as theirbreathing rate and to alert staff if a patient’s condition wasdeteriorating, and requiring medical advice or intervention.

There were risk assessments undertaken for each patientwithin six hours of admission to a ward. These included

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assessments for risk of malnutrition, developing pressureulcers or VTE and risk of falls. On ward 2A we noted that afalls risk assessment had not been undertaken for onepatient and there was no explanation for this.

Care plans were developed to manage identified risks andensure safe and appropriate care. Risk assessmentdocumentation was standardised across all of the wardswe visited; however, care planning documentation varied,as did the recording methods to demonstrate that riskswere being appropriately managed. We noted on a traumaward that a patient who was immobile had been identifiedas being at risk of developing pressure ulcers. In order tomitigate this risk, the patient was to be turned every threeto four hours. A senior nurse told us that turn charts werenot used to evidence this support but this would berecorded in the daily records completed each shift. Welooked at the records and saw that there were regularreferences made to the condition of the patient’s skin so wecould see this was checked but they did not evidence thatthe patient had been turned as specified in their care plan.

Staffing arrangements impacted on safety. There werenursing and healthcare assistant staff shortages reportedon surgical wards and in theatres. In the neurosciences,orthopaedics, trauma and specialist surgery division, thevacancy rate for nursing staff was 16.4% in December 2013.The trust told us there had been a recruitment drive and arecent cohort of registered nurses from Spain had recentlybegun work. Recruitment was ongoing and furtherrecruitment drives in Scotland and Wales were alsoplanned.

On the neurosurgery ward on one day of our unannouncedvisit, two beds were closed due to a shortage of staff. Apatient was waiting in ITU to be transferred to the ward butthere were no beds available, putting pressure on staff todischarge to create capacity. Two staff on this ward told usthat there were frequently insufficient staff. The daypreviously they reported they had been one registerednurse short. They said that beds were frequently openedfor emergency admissions, even though there wereinsufficient staff. Staff thought this was unsafe. Thedivision’s risk register noted “insufficient theatre capacity tomanage emergency and elective workload withinneurosciences. This can result in cancellation of electivecases and the ward frequently running at over 100%capacity.”

In theatres the vacancy rate was of concern. The vacancyrate for the clinical support services division was 2.98% inNovember 2013 but in the division’s January 2013 qualityreport it was noted that theatres was a “hotspot”. At thetime of our visit the operational services manager in theclinical support services division told us there was a 19%vacancy rate for nursing and medical staff. In addition therewere a number of staff on long term absence. This meantthere was regular and frequent use of temporary (bank andagency) staff. Staff shortage was recorded on the riskregister for theatres. Some temporary staff had beenemployed on long term assignments to help ensurecontinuity. Staff told that they regularly worked long daysor did overtime on the bank. However many staff werefatigued and were volunteering less. Staff reported highlevels of stress and low morale due to workload. Thedivision reported that they were investigating the reasonsfor staff turnover.

The senior theatres and CSSD manager told us thatoperating lists were cancelled about once week due to staffshortage. Theatre staff told us that sometimes theatres hadonly two theatre staff supporting the surgeon andanaesthetist. The Association for Perioperative Practice(AfPP) recommends that there should be three staff (threenurses or two nurses and one operating departmentpractitioners (ODPs). Staff in the main theatres told us thatthey regularly had only two staff. They said this occurredapproximately once a week. They said this had thepotential to be unsafe.

In neurosurgery junior doctors told us that sometimes themedical staffing levels felt unsafe. Out of hours there wasone junior doctor (Senior House Officer) looking after 74inpatients, while a registrar provided emergency cover.There was no phlebotomy service, which added further totheir workload. We saw this in practice during ourunannounced visit.

In trauma services junior doctors felt the medical cover wassafe and they felt well supported with resident registrar andconsultant back up always available, including out ofhours. Similarly, on the emergency surgical unit, junior stafffelt well supported by senior clinicians.

Neurosurgeons told us that lack of theatre capacity meantthat elective surgery was cancelled in order toaccommodate emergency work. However, they also told usthat there was pressure from management to meet targetsfor elective work and they needed to operate at night to

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complete this work. The senior theatres and CSSD manageraccepted this practice was unsafe and told that it had beenstopped. The trust told us that as a policy electiveoperations are not conducted after 8pm.

The suitability and condition of premises was varied.Surgical wards were well laid out, with provision for closeobservation of acutely unwell patients and barrier nursingof infectious patients. Wards were clean and there wereappropriate arrangements for cleaning and the disposal ofwaste. There were adequate hand washing facilities andpatients told us they saw staff regularly washed theirhands. Staff observed the “bare below the elbow” uniformpolicy and wore suitable protective clothing such as glovesand aprons, which were in plentiful supply.

Each ward was equipped with an emergency resuscitation(crash) trolley. We checked this on a neurosurgery ward andfound that a piece of equipment was missing. This hadbeen identified two days earlier but had not been rectified.

However, staff expressed concerns about the condition ofthe main theatre suite. We were told by a senior nurse thatthere was a rusty sink in one theatre.

Monitoring safety and responding to riskThere 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.

There was an infection control link nurse in the maintheatres department but they did not take part in theregular “walkabouts”. We asked one of the departmentalsisters if joint theatre inspections took place with estates,infection control leads, and clinical staff. They said they didnot. The general manager told us that any concerns aboutpremises would be escalated via divisional clinicalgovernance meetings. Minutes of trust-wide clinicalgovernance meetings did not identify any concerns of thisnature.

Anticipation and planningOn 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 a

higher level of observation, for example, then workload wasdiscussed at handovers and organised to facilitate therequired level of support. Staff told us that they couldrequest additional staff to facilitate intensive monitoring.

Planning for surgical procedures was not done well. Pre listbriefings took place prior to each list commencing, wherethe whole team discussed the planned cases anddiscussed issues, such as equipment, timings, andindividual roles. There were regular planning meetings butoperating lists were open ended, which meant on the daybefore or the day of surgery staff were, as one staff memberdescribed it; “scrabbling around juggling cases and tryingto find the appropriate number of staff.”

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

Good –––

Using evidence-based guidanceDivisional quality reports showed how each division wasperforming in relation to guidance from the Nationalinstitute of Clinical Excellence (NICE). The trust wasdelivering care in line with guidance on the treatment ofhip fractures but was only partially meeting guidelines inrelation to pre-operative tests. There were action plans inplace to show what needed to be done to ensure practicewas in line with guidelines.

Performance, monitoring and improvement ofoutcomesPerformance on patient reported outcome measures(PROMs) was gathered from patients who had groin herniasurgery, or varicose vein surgery. Patients were asked aboutthe effectiveness of their operation and the response datashowed no evidence of risk and good outcomes forpatients. The trust achieved compliance with the ninestandards of care measured within the National HipFracture Database. The rate of unscheduled return totheatre (specialist surgery) from November 2012 toDecember 2013 ranged from 0% to 4%.

Staff, equipment and facilitiesThe senior theatres and CSSD manager told us “theinfrastructure is not optimal” and described a “constantwrangle with the estates department to get basic workdone”. There were regular “walkabouts” conducted by the

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theatre sisters to monitor the safety and cleanliness ofpremises. Identified concerns were recorded on thedepartment’s risk register. Staff told us that there was noseparate scrub room which was “not ideal”. Department ofHealth guidance (HBN 26 Facilities for surgical procedures)states: “where a scrub room is shared between theatrespotential exists for the compromising of pressure gradientswithin and between the two theatres with possible adverseconsequences for infection control.” Concerns were alsoraised that some theatres were not large enough toaccommodate necessary equipment. The trust were awareof the concerns and plans were in place to refurbish thetheatres at the hospital.

The senior theatre and CSSD (central sterile servicesdepartment) manager told us it was recognised thattheatre utilisation had to be improved. In January 2013 itwas reported in the division’s quality report that the theatreutilisation rate was 75% for planned surgery and 56% foremergency surgery. It was also reported that a theatresimprovement programme steering group had been set upand a new trust-wide booking process had beenintroduced.

We asked staff at all levels whether they felt well supportedwith training and supervision. Responses varied. Nursingand junior medical staff working in trauma felt wellsupported by their peers, senior clinicians, and managers.A newly appointed staff nurse on a trauma ward told ustheir ward was an amazing place to work. They told usabout their in-depth induction in trauma and their ongoingsupport and supervision from team leaders. Inneurosurgery, junior medical staff were concerned thatpressure of work impacted on the time available to themfor training. They told us that training and theatre time wasnon-existent.

Staff working on the trauma wards were positive about thelayout, facilities and the way in which workload wasorganised on the wards’, all of which they felt allcontributed to effective care. There was a mixture of fourbedded bays and some single rooms for patients whorequired barrier nursing. There were observation bays insight of the nurses’ station so that more vulnerable anddependent patients could be closely observed.

All patients were allocated a primary nurse to ensurecontinuity of care. At each shift change there was a whole

ward handover, followed by a one-to-one handoverrelating to each patient, so that staff were well informed.Primary nurses, where possible, joined ward rounds withvisiting doctors so that care was co-ordinated.

Multidisciplinary working and supportWe saw examples of good team working and peer support.Clinicians working in trauma surgery were proud of themultidisciplinary and integrated approach to caring forpeople with complex needs. As a major trauma centre, theservice treated a wide range of trauma conditions. Manypatients had multiple injuries and some, particularly olderpeople, had co-existing illness and/or cognitiveimpairment. Two ortho-gerontologists (doctors whospecialise in caring for older people with orthopaedicinjuries) worked Monday to Friday on trauma wards toprovide medical input and ensure an integrated approachto their care and treatment. Staff were supported to studyfor a diploma in gerontology and there were regularteaching sessions to help them understand the needs ofolder people. A locum consultant surgeon who hadrecently worked on the trauma wards had written to thematron saying “I believe the team working in the traumaward is outstanding and offers the patients an unbelievablehigh quality of care. I had great feedback from patients inthis regard.”

There was a nurse consultant in trauma care. This was thefirst such post in the UK and was developed to facilitateand co-ordinate shared care of complex trauma cases andprovide expert input into trauma care in other departmentssuch as children’s services. A grateful patient had written: “Icannot tell you how reassuring it felt to know that therewas somebody who knew me. Somebody that didn’t justknow me for the fractures, wasn’t there just for the surgery,somebody who knew about my time, not just on trauma,but on intensive care and specialist surgery wards as well.”The nurse consultant had also formed links with traumaservices in other district general hospitals and worked withcommunity hospitals to develop designated beds forpeople with hip fractures, requiring rehabilitation.

Surgery



Are surgery services caring?

Good –––

Compassion, dignity and empathyPatients on surgical wards were treated with compassion.We saw a letter written by a junior doctor to the matron,praising the “superb team of nurses” working on thetrauma wards. They had witnessed a nurse on ward 3A whowas looking after a very distressed, delirious, elderlypatient with a fractured hip. They said on a busy night shift“[The nurse] sat with this patient for several hours,reassuring them and holding their hand with their left handwhile doing their admin with their right hand.”

Patients’ privacy and dignity were respected. All of thepatients we spoke with told us they were treated withcourtesy and respect. We noted that curtains were drawnaround patients’ beds when personal care was provided.Ward accommodation was segregated so that men andwomen were afforded privacy and dignity. However, thiswas not the case on the theatre direct admission unit,although an audit had shown that patients did not feeluncomfortable with this arrangement.

Patients told us they had enough to eat and drink andthere was a plenty of choice with their meals. Most peoplefelt that the quality of the food was adequate or good. Weobserved that patients had jugs of water by their beds andthese were regularly topped up. Patients had access to callbells which they could use to call for assistance. We notedthat these were always within easy reach. Patients told usthat staff responded promptly when they called for help.

Patients and staff told us that nursing staff conductedregular ward rounds to check that people werecomfortable. Patients were regularly asked about their painlevels, particularly immediately following surgery. Patientstold us if they asked for pain relief this was arranged andadministered promptly.

In the Patient Led Assessment of the Care Environment(PLACE) in 2013, the John Radcliffe Hospital scored over90% for cleanliness, over 80% for facilities and privacy,dignity and wellbeing. The lowest score was for food whichscored 73.4%.

Involvement in care and decision makingPatients and those close to them told us they were wellinformed about their medical condition, their care, andtreatment. They said that nursing and medical staff hadexplained everything to them in a way that they couldunderstand and they understood the risks and benefits oftreatment. Consent procedures were followed anddocumented. On trauma ward 2A we saw a letter from agrateful patient to the trauma nurse consultant. They said:“Being in hospital is a strange experience... Throughout itall I knew I was being cared for and in the best place;everybody was kind, patient and always gave me as muchinformation as possible as to what was happening andwhy”. One patient told us that each time they were giventheir medicines, staff explained what they were giving themand the dosage. They appreciated that while they foundthis tedious; it was a safe practice and one which ensuredthat they retained some control.

In the 2012 Adults in patient survey the trust performedbetter than other trusts in response to the followingquestions; “Did a member of staff explain the risks andbenefits of the operation or procedure?” and “Were youtold how you could expect to feel after you had theoperation or procedure?”

Trust and communicationPatients told us that things were explained to them in away they could understand. One patient complimented thedoctor’s bedside manner. They said they were put at easeand felt able to ask questions. Another patient told us theyappreciated the clarity and the openness of the medicalexplanations given to them. They were encouraged to askquestions if they did not understand. Patients were wellinformed about their medical condition and theirtreatment. The risks and likely outcomes of surgery hadbeen explained to them and they had been asked for theirconsent. There was a range of patient literature available,both on the wards and on the trust’s website. Translationand interpreter services were available for people whosefirst language was not English.

Emotional supportPatients and relatives told us they received the supportthey needed to cope emotionally with their treatment andhospital stay. A relative who had been very anxious about

Surgery



their family member told us they had been made to feelwelcome on the ward and had been supported and keptinformed. There was a chaplaincy service available forpeople of all religious denominations.

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


Meeting people’s needsMost patients told us that all of the staff were responsive totheir needs. One patient said: “nothing is too muchtrouble.” Most people who had used their call bells whenthey needed help said, staff always responded quickly. Oneperson on a trauma ward told us that they needed painrelief in the middle of the night and this was arrangedwithout delay. However, a patient on the neurosurgeryward told us that staff were slow to respond to calls for helpand felt that staffing levels were inadequate.

The hospital worked towards achieving national targets inrelation to waiting times, cancelled operations, anddelayed discharges. The NHS constitution sets out thatpatients should not wait more than 18 weeks for treatmentfrom the time they are referred. Overall data for the trustfailed this target for patients who were admitted, achieving88.06% against a target of 90% as at November 2013.Eleven patients waited over 52 weeks; nine patients fororthopaedic surgery, one maxilla-facial surgery and one forpaediatric spinal surgery.

Department of Health guidelines state that if patientsrequire surgery and their operation is cancelled fornon-clinical reasons, their operation should be re-arrangedwithin 28 days. The trust scored similar to expected whencompared with other trusts in relation to cancelledoperations. However, staff told us that operations wereregularly cancelled due to lack of theatre capacity, shortageof staff or inefficient planning. Cancellation data providedby the trust showed that overall the cancellation rate was0.63% for the period 1 April 2013 to 31 December 2013. Thehighest rate was categorised “unknown”. This requiredfurther explanation and investigation. High rates were alsorecorded in cardiac surgery (5.3%) and neurosurgery(3.85%).

There were numerous comments from staff about theinefficient system for planning theatre lists and someconcerns expressed about the administration of theatrelists. Several examples were described where patients didnot arrive because they had not received notification oftheir surgery. A relative told us that their family memberhad received three letters inviting them for surgery whichhad already taken place.

A manager described the planning of theatre lists as“chaotic” which had implications for efficiency and safety.They told us lists were put together by surgical divisionsand were very often unrealistic and overran. They said thatnon-clinical staff (secretarial) were prioritising patients andplacing them on operating lists in a “disjointed way.” Theytold us that there were “pockets” where patients were notbeing properly assessed prior to surgery and operationswere cancelled due to the patient not being fit. Aconsultant surgeon told us: “Operating lists are run ongoodwill, rather than good planning.”

A theatre manager told us there were significant issuesaround the management of the 18-weeks target which ledthe theatre lists being over booked. If emergency casesarose, planned surgery was cancelled. We heard that thatoperating lists were “chopped and changed on the day”and that there was no real planning. Concerns were alsoraised about the inconsistency of surgeons’ practices, withsome starting at 9am and others starting at 11am. In thewest wing theatres an anaesthetist told us that theout-of-hours emergency theatres were inefficient becausethe specialist theatre teams (neurosurgery, maxillofacial,ENT, paediatrics, and plastic surgery) were on call andtherefore there were frequent delays. They told us thatemergencies were prioritised but patients’ operations werefrequently delayed. We were told that recently a patientwith a fractured jaw waited two days, without food eachday, until they had their surgery.

A maxillofacial surgeon told us the service struggled tomeet increasing demand and that access to emergencytheatre was a particular problem. They told us this resultedin poor patient experience and that delays had led to somepoor outcomes for patients. Delays also impacted on the18-weeks referral to treatment target.

In neurosurgery medical staff told us that there wasinsufficient theatre capacity to cope with the emergency

Surgery



demand. This meant that elective surgery was oftencancelled. Nursing staff told us sometimes patients werewithout food for up to 24 hours, because their surgery asconstantly delayed.

The risk register for the trauma directorate recorded thatpatients with fractured femurs were failing to receivesurgery within 36 hours because theatre capacity/efficiencycould not accommodate peaks in demand. The qualityreport for the specialist surgery division showed that thetarget of 70% had been exceeded, with 72% of patientsreceiving surgery within 36 hours in the quarter ending 31December 2013.

Theatre staff told us they had concerns about the lack oftheatre capacity, the suitability of premises, and theavailability of equipment. In the main theatres, capacityhad been reduced recently due to the closure of twotheatres.

Staff in theatre recovery reported that staff shortages onsurgical wards meant that recovery nurses had to takepatients back to the ward. This meant that they weresometimes away from the recovery department for 20 to 30minutes. The impact of this was that there were sometimesdelayed transfer of patients from theatre to recovery, and inturn, further delays in theatre.

Vulnerable patients and capacityThere was insufficient attention paid to the identification,assessment and planning of care needs for vulnerablepeople. There was recognition that a large proportion oftrauma patients were older people who may have complexor special needs, including dementia. The trust wasrequired to screen patients over 75 years of age if they wereadmitted as an emergency and remained in hospital forover 72 hours. The trust’s performance in November 2013was 6%. The neurosciences, trauma, orthopaedics andspecialist surgery division reported in their January qualityreport: “there is a drive to raise the profile with dementiascreening.”

Some patients, who required a period of rehabilitation,continued to be cared for on acute surgical wards followingthe acute phase of their care pathway. This was because ofa shortage of suitable placements in, for example,community hospitals. On the emergency surgical and

trauma wards there was support from physicians anddoctors who specialised in the care of older people. Weheard about plans to develop a ‘dementia friendly’environment on some wards.

On a trauma ward we looked at two care plans for olderpeople. One patient was recorded as having “knowndementia”. The second was recorded as “query dementia.”In both cases there was a pre- populated, semi structuredcare plan for people with dementia. Prompts included:“assess patient to find out best way to communicate” and“complete ‘knowing me’ form.” (‘Knowing me’ is a profilecompleted for people who have limited capacity or areunable to communicate their needs and is often completedby people who are close to them.) Neither of these actionshad been completed for either patient, despite the fact thatthey had both been inpatients for over a week. We wereconcerned that staff, particularly temporary staff, may nothave sufficient information about each of these patient’sparticular needs to ensure that their needs could be met.We were shown a new template for a dementia action planwhich was to be introduced on the ward the followingweek.

On a neurosurgery ward a generic care plan had beendeveloped for an elderly patient with dementia. There wasno detailed care plan to indicate any special needsassociated with their dementia. Similarly, a care plan for apatient who was being fed via a nasal gastric tube was toogeneric and did not contain sufficient detail to ensure thatstaff understood their needs.

Access to servicesAccess to services was variable because the hospital had ahigh occupancy rate (92% trust-wide between July andSeptember 2013). There was limited access for somepeople who required a period of rehabilitation, to suitableplacements in the community.

Leaving hospitalDepartment of Health guidelines state that patients shouldbe discharged from hospital when ready and withinformation and support available to them to ensure theydo not need to be re-admitted. Patients should haveadequate notice of their discharge and it should not bedelayed due to waiting for medicine, to see a doctor or foran ambulance. The clinical support service quality reportreported in January 2014 that the turnaround time forpharmacy to fulfil prescriptions for patients to take homerequired improvement. The target was that 90% of

Surgery



prescriptions should be fulfilled in less than 90 minutes.Performance in December 2013 was 59% for weekdays and47% for weekends. The trust was aware of this, through theinternal peer review process conducted from November2013 to January 2014. Work had commenced to resolve thisissue.

In the CQC survey of adult inpatients (September 2012 toJanuary 2013) the trust scored similar to expected whencompared to other trusts in relation to these targets.However, some patients remained in acute wards for toolong because suitable placements to support theirrehabilitation could not be found.

Most of the patients we spoke with had been giveninformation about their discharge from hospital and theyknew when they were expected to be discharged. They hadbeen assessed by physiotherapists and occupationaltherapists and asked about their home circumstances andthe support available to them. Arrangements wereconfirmed about how they would get home. These wereknown as simple discharges. However, for some patientsthe process was more complex because care packages hadto be arranged to support their rehabilitation in thecommunity. This often led to delayed discharge which leftpatients feeling frustrated and anxious.

Staff told us that patients’ discharge was planned as soonas they were admitted. We saw that an estimated dischargedate was recorded in their notes. They told us that patientswere given information about their surgical proceduresbefore their admission and this included information aboutafter care. This was reinforced on their discharge.

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 wards we visited had received few complaints. Weasked staff if there were any themes. Most staff could notthink of any but on one ward a staff member told us the

most common complaint from patients was the cost andunreliability of the televisions provided by patients’ beds.They told us they passed the information on but felt thatthe solution was out of their control.

The hospital routinely captured feedback using the friendsand family test. Staff told us that results were regularlydiscussed at team meetings.

Are surgery services well-led?


Vision, strategy and risksThere was a clear trust vision and a set of values, whichwere patient focused. Many staff did not know what thevision and values were but portrayed similar values andpassion and motivation 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. Although there was someevidence of cross divisional working, for example, thetheatres improvement programme steering group, this wasnot sufficiently embedded to be effective. For example, thecomplex issues relating to inefficient theatre use, whichinvolved key staff working in different directorates.Contributing factors including staffing issues, premises andadministration processes but these were not yet beingaddressed in a joined-up way.

Leadership and cultureMany of the staff we spoke with felt well supported by theirimmediate managers. For example, in trauma services, astaff member described a “very well-led service with goodmultidisciplinary team working”. There were mixed viewsabout the provision of training, support, and supervisionfor staff. Staff in the trauma service felt well supported bysenior clinicians and were well supported with training. Theclinical director and matron sent letters of commendationto junior medical staff who had “gone the extra mile anddeserved recognition”.

Staff in theatres had experienced many changes inmanagement and did not feel that the department waswell led. Staff shortages meant that senior staff provided

Surgery



clinical care and could not fulfil their managerial roles.Some new interim managerial appointments had recentlybeen made. They acknowledged the lack of senior clinicalleadership had begun to engage with and support staff.

Some staff felt that the executive level management wasneither visible nor accessible. We were approached prior,during and following our inspection by 21 senior clinicians(doctors and nurses) who had serious concerns about theculture of the organisation. Many of these staff wereanxious that they would not be identified aswhistleblowers. Some clinicians felt they weredisempowered and did not have a voice. Staff talked of aleadership style which they perceived as limitingautonomy, creativity, and flexibility. This was in contrast tothe views of the Chief Executive who describedencouraging innovation and autonomy.

Some of the consultants described their dissatisfactionwith their job plans and the process by which they weredeveloped, saying they felt there had been little room fornegotiation. Four consultants told us they had had theirperioperative care time (care given before during and aftersurgery) cut and said they did not feel able to deliver theservice safely within these constraints. Job plans are jointlyagreed plans which set out a consultant’s responsibilitiesand objectives. They set out what work is to be done,where it is be done and the time and resources required toachieve objectives.

There had been a high turnover of senior nurses and it wasfelt that nursing leadership had been a factor in this.Theatre staff told us there had been five theatre managersin the last five years and the post was about to becomevacant again. Some staff felt that morale was low and stresslevels were high. One senior nurse told us “This has beenthe worst four years of my career. Care is second to nonebut we are stressed on a daily basis.” Several senior nursesconfirmed that work related stress was a major factorwhich led to nurses taking less senior positions, leaving thetrust or the profession. This was in contrast to theimproving results in the staff survey.

A junior doctor contacted us highlighting a number ofconcerns about the management of the anaestheticsdepartment; in particular there were issues withcommunication and with staff working hard but not feelingsupported. They told us there had been a succession oftheatre managers in the west wing and they felt that theywere not sufficiently visible or accessible.

Patient experiences, staff involvement andengagementPatients’ views and experiences were a key driver for howservices were provided. There was information displayed inwards showing how the ward was performing and what thefriends and family test results were telling them. Patients’views and experiences were taken into account in theplanning and delivery of services.

Staff at local level staff felt involved and engaged in makingthings work and constantly improving standards of care.However, there was less engagement about, orunderstanding of, other drivers, pressures and challengesand some staff did not see opportunities to have opendialogue about problems or solutions. Many theatre staffwere concerned about the condition of the premises in themain theatre suite, which were not considered to be fit forpurpose. Staff talked about plans to build new theatres buteven senior staff were ill informed about the timescale forthis and what could be done in the meantime to addressthe issues of concern. They expressed frustration that theywere not able to influence change.

Learning, improvement, innovation andsustainabilityThere was eagerness to learn and to constantly improvecare and treatment. However, some senior clinicians wereconcerned that innovation was stifled and opportunities forlearning were limited because of financial and demandpressures. Consultants told us they were having their timefor supporting professional activities (SPAs) cut to aminimum (one). This meant that they had less time forteaching, research, and personal development. The trustprovided us with a sample of eight anonymised job plans.Four of these had one SPA; the remaining four had between1.5 and two. The trust had approved job planning processwhich had been consulted on. This process required all jobplans to be structured at a baseline of nine direct clinicalcare programmed activities and one supportingprogrammed activity. All job plans were negotiated fromthis baseline dependent on the trust’s needs and individualroles. This incorporated specific additional SPAs forapproval trust activities including clinical, managerial,teaching or research.

Surgery



Safe Good –––





Information about the serviceThe critical care unit at John Radcliffe hospital has 19 beds.There were arrangements to provide 24 critical care bedsbetween the adult intensive care units at John Radcliffehospital and Churchill Hospital. This allowed for flexibilityof how many beds were available at each hospital butwould not exceed a collective bed number of 24. Criticalcare covers both intensive care and high dependency care.These are defined as level 2 being high dependency andlevel 3 being intensive care beds. The critical caredepartments at John Radcliffe Hospital included the adultintensive therapy unit (ITU) 19 beds, the cardio thoraciccritical care unit (CTCCU) 19 beds, and the neuro-criticalcare unit 13 beds. There were also six high dependency unitbeds (HDU), which formed part of the Coronary Care Unit.

A critical care outreach service to assess patients on thewards to be admitted to the intensive therapy unit was notavailable. However, systems were in place to escalatepatients with deteriorating health. A patient follow upsystem was in place to ensure patients leaving critical careand returning to the wards were well supported. There wasconsultant cover on all of the departments 24 hours eachday.

We talked with four patients, this low number was due tothe difficulties in communicating with some critically illpatients and our wish not to tire or disturb them. We spokewith six relatives visiting the adult intensive therapydepartment, cardio thoracic and neuro-critical care unitsand 23 members of staff. These included nursing staff,consultants, junior doctors, and management of the units.Before our inspection, we reviewed performance

information from, and about, the trust and listened tocomments from people at our listening events. We alsoreviewed data from the Intensive Care National Audit &Research Centre (ICNARC) for April 2012 to March 2013.

Intensive/critical care

Good –––


Summary of findingsPatients received safe and effective care. While staffrecruitment and retention was recognised by the seniorstaff as an issue, the levels and skills of staff on aday-to-day basis were consistently managed. Clinicaloutcomes were monitored and demonstrated goodoutcomes for patients.

Patients and relatives told us the caring, considerationand compassion of staff was of a very high level.Considerable work had recently been undertaken toimprove the responsiveness of the service to ensurepatients were discharged when they were ready anddelays were minimised. This also improved theresponsiveness for pre-planned admissions followingsurgery to take place. The departments were well ledand demonstrated a positive leadership and culture. Abusiness case had been submitted to the trust toincrease in intensive care and high dependency beds inorder to improve care and meet the identified demandas the service sometimes runs at over 100% capacity.

Are intensive/critical services safe?

Good –––

Safety and performanceThe monitoring of safety takes place to promote patientsafety. Each critical care unit used a standardised record formeasuring their performance and so all safety data wascomparable. This increased the learning available to eachcritical care unit. The areas covered included a monthlycheck on infection control assessments, falls, urinary tractinfections, and incidents relating to pressure damage. Thehospital trust contributed their data to the Intensive CareNational Audit and Research Centre (ICNARC) in order thatthey could be evaluated against similar departmentsnationally. The results of this and all monitoring wasreviewed and discussed at divisional meetings each month.Further data was also monitored monthly which related tothe views of patients and their relatives. The commentsmade by patients and relatives were used when needed tochange practice on the units. We saw that when an issuehad been identified a response and action plan was put inplace and this information was put on notice boards toinform relatives of the plans for change. Two relatives toldus that at a time when they felt a loss of control they hadfound this openness reassuring.

Patients and their relatives felt care was safe. We observedcare being given and saw staff following the safety checkingpolicies provided by the trust to promote patient safety.These included infection control procedures such as handhygiene and medicine management polices to reduce therisk of medicine errors.

We saw that the environment of the three units within JohnRadcliffe Hospital varied as the cardio thoracic andneuro-critical care units being more updated and largerclinical areas which were easier to clean and had betterstorage. The adult intensive care unit was less suitable forpurpose. However, the staff on each unit received the samesafety information and followed the same procedures tomaintain safety for patients.

Learning and improvementStaff told us and records showed they learned fromuntoward events.


Good –––


All serious incidents were recorded through the incidentreporting system and were investigated and discussed atthe divisional governance meetings. Staff told us thatlearning from all of the critical care units was shared todevelop and improve practice. We saw that an incident hadoccurred during a patient transfer. As a result of thefollowing investigation a training need had been identifiedand a programme to suit the needs of the trust devised andimplemented. All critical care staff had received transfertraining to promote the safety of patients during hospitaltransfers.

Systems, processes and practicesSystems for patient records were managed safely. Thepatient record systems in place varied between each unit.The cardiothoracic and neuro-critical care units hadcompletely electronic records. The adult intensive care unithad a mixture of electronic and paper records. Theelectronic records were not all compatible with each otherand none were compatible with the rest of the hospital.The trust told us there were systems in place toaccommodate this.

Nurses used an electronic system for care records andinformation. This excluded do not attempt resuscitationrecords. Doctors maintained paper records. While therewas a variation, staff confirmed that this did not affect thesafety of patient care. All electronic stored information wasbacked-up and could be transferred into paper records inpreparation for transfers to other wards when patients weredischarged. We saw that systems relating to medicineadministration had been identified on one unit as a risk.This was because the medicine charts were stored on thecomputer and the medicines were stored in a lockedcupboard by each bed, away from the computer. Newpolicies and procedures were being planned to inform staffhow this should be managed in a procedural way toprevent medicine errors taking place. Electronic prescribingsystems had been implemented and staff told us that thisworked well and was effective for patients and staff.

Infection control and hygiene was monitored and theresults made public on each unit. The trust’s infection ratesfor Clostridium Difficile and MRSA lie within a statisticallyacceptable range, taking into account the trust’s size andthe national level of infections. On the adult intensive careunit hand hygiene was assessed at only 87% completedand cleaning at only 83%. The matron advised thatongoing works takes place to review all areas audited. We

observed good hand hygiene taking place in all areas.However, we noted that staff did not adhere strictly to theuniform policy with hair touching collars and earringswhich was not in line with the trust policy.

Monitoring safety and responding to riskMonitoring systems were used to make improvements tosafety and work practice. As a result of identification ofpatient delays to admission and transfer, in December 2013a programme of action had been developed to change howthe units managed their admissions and discharges.Changes included a review early each morning to establishif beds would be available for the planned theatreadmissions that were known to have a need for apost-surgery critical care bed. This enabled staff tocommunicate earlier with theatre staff to plan the theatrelists and promoted a more effective way of working.

The critical care departments recognised and understoodrisks. The managers for each critical care unit decided whatrisks were escalated to the service risk register and howthey were to be managed.

All deaths on the critical care units were reviewed to informand direct current practice. Monitoring of mortalityincluded comparisons to other trusts. We saw that ICNARCdata from first two quarters of 2012/13 showed that allthree units had a Standardised Mortality Ratio (SMR) thatlay comfortably on or below (better than) the mean value.

Anticipation and planningPlanning has taken place to develop the critical care andhigh dependency beds needed by the trust. Theconsidered lack of high dependency beds meant that therewere delays discharging to the wards from critical careunits. The lack of critical care beds meant patientsdeteriorating on other wards did not have swift access tohigher dependency beds. We were also told that a lack ofhigh dependency beds impacted on planned surgicaloperations taking place and in some cases caused theseoperations to be cancelled. A business case had beensubmitted to the trust as staff had identified the demandfor level 2 high dependency beds.

Further agreement had also been reached for threeconsultant posts to be filled to support the critical careunits.

Are intensive/critical services effective?


Good –––


(for example, treatment is effective)

Good –––

Using evidence-based guidancePatients received care in line with national guidelines.

We saw that the management of skin damage by pressureor moisture damage was effective. A tissue viability nursewas available on the unit who ensured staff were kept up todate with new methods and equipment. Trolleys ofdressings had been made available on the unit to enablestaff to access the equipment they needed quickly andeasily. Nursing staff showed us that tissue viability wasincluded on their observation records to prompt them toseek review and records included a wound care plan if seento be needed. All grade three damage was recorded as anotification to inform the hospitals auditing process. Thiswas discussed at clinical governance reviews to consider ifthe current methods of management were effective. Thetissue viability lead audited all pressure damage daily andthe auditing showed a reduction in skin damage. Anylearning outcomes were shared across all of the criticalcare units. However, it was noted that the high health risksof patients receiving critical care often meant that pressuredamage could not always be avoided.

The management of deep venous thrombosis wasrecorded electronically and staff reviewed equipment andmedication needed routinely to reduce the risks to patientsof thrombosis. A warning on the electronic recordingsystem reminded staff to complete this area or remindedthem if a review was due. Staff monitored any urinary tractinfections and reviewed the cause. Recording of all of theseareas was open to the public as results were madeavailable on notice boards on each unit.

Performance, monitoring and improvement ofoutcomesOutcomes for patients were good.

Mortality rates, which are measured nationally, had notbeen raised as an area of concern at John Radcliffe

Hospital. Patient transfer to other departments andhospitals in the night had reduced and any transfers atnight were reviewed and investigated. The ICNARC data forthe first quarter of 2013 showed that there were delays offour hours and above for patients being discharged from

critical care units. The Matron assured us that latest datahad showed this trend had slowed and was improving.Staff confirmed a significant improvement in delays ofdischarge.

We saw from the electronic records that recording ofconsent was not prompted by the electronic system.However, discussions with staff and observations of carebeing provided showed that while not well recordedconsent was actively sought on all levels including consentto provide personal care and included consent to changeposition.

We reviewed records for those patients who had a decisionnot to be resuscitated in the event of a cardiac arrest. Wesaw that they had been fully completed and staff explainedwhat action would be taken should the patient not be ableto participate in the decision process. They demonstrated agood understanding of whose best interests must beserved. Staff told us that at each handover the status forresuscitation was confirmed and that reviews of thedecision not to resuscitate were taken before the patientleft the department.

Staff, equipment and facilitiesPatients told us “They [staff] have been marvellous” and“They are worth their weight in gold”.

Relatives also told us: “The care has been excellent, I knowwhat is going on, I am kept up to date on any changes or anissue on the unit with my relative” and “staff are just fab!”Two relatives said that while they had no criticism aboutstaff but sometimes wished there were more staff availableto prevent the wait needed to turn patients to relieve skinpressure. However, they told us that at no time was thequality of care compromised.

There were sufficient medical staff and consultant staffavailable 24 hours per day and 7-day cover was providedon all critical care units. Medical cover was rotated everythree to four weeks over the John Radcliffe and ChurchillHospital adult intensive care units. Doctors felt wellsupported and had unlimited access to senior medicalstaff.

A pharmacist was allocated to each critical care unit andreviewed all medical prescriptions daily to ensure sufficientstocks were available and they were available to advise onall areas related to medicine practice.


Good –––


Staff told us that sometimes they felt that they were verybusy but staffing levels remain stable with agency andcontingent workforce staff made available when needed.Staff told us there was no pressure to work extra hours. Thiswas despite the NHS staff survey in 2012 which said thatthe percentage of staff working extra hours was worse thanexpected. The recruitment and retention of nursing staffremains a problem area for nurses due to the geographicallocation of the hospital. This has been raised to thedivisional and directorate risk register for the trust.

The trust continues a foundation training programme forall nursing staff to ensure sufficient training in critical care.This included competence assessment and observation ofcare being provided. An induction programme took placefor all new staff and they confirmed it was informative andsufficient at the start of their critical care role. Furtherspecialist training packages were available to support staff.A mentorship programme by band 7 nurses providedfurther support to new and existing staff. An education leadnurse was available and told us that sufficient support andresources were available to ensure training and supportwas provided to all new staff. Weekly training sessions tookplace, tissue viability and moving and handling trainingtook place during inspection, and we observed band 5trained nurses shadowing more experienced staff toobserve practice.

Staff told us that they were proud of the units they workedon and enjoyed having the time to provide the highest levelof care. They told us the hospital provided them with goodlearning and development opportunities and thatdiscussions with Matron were always possible to highlightany ideas they had. Staff survey results highlighted ashortage of information and support for staff to deal withdifficult situations. As a result a psychologist had beenvisiting the units to support staff to manage challengingand emotionally difficult situations.

Staff worked between three hospitals and a system was inplace whereby staff rang a taped message each morning tofind which unit they were worked on that day. Staff told usthat this system was not a problem to them.

Facilities in the cardio thoracic 19 beds, coronary care unitsix beds and neuro-critical departments 13 beds were of ahigh standard. The departments were purpose-builtdesigned with input of experienced critical care staff. Herewas capacity for level two and three patients. This meantthat patients who required artificial ventilation could be

cared for as well as patients with less intensive needs butstill had needs which could not be met on a main ward.Staff had identified a need for further reception staff tocover the evening as this was found to be a shortfall in the”front of house” service provided.

The adult intensive care department was equipped for upto 19 patients with a flexible arrangement with ChurchillHospital to accommodate up to 24 patients between them.The trust’s bed occupancy average for July to September2013 had been higher than the England average and abovethe recommended rate of 85%. However, for critical carebeds, the trust’s occupancy rates had been lower than theEngland average for the period of September to November2013. During January 2014 the adult intensive therapy unitran in excess of the 19 beds at around the 108% capacity bycreating extra bed space. This was due to the high demandfor critical care and high dependency beds.

The adult intensive therapy unit was less spacious andsuitable for purpose. Care was provided and the areasmanaged as well as staff could. However, the single roomswere noted to not all have natural light, no overhead hoistequipment and very limited space. Male and femalepatients were cared for in the same space; however,curtains were available around each bed for privacy anddignity.

Accommodation was available on all of the units forrelatives to stay overnight. There was also a sitting roomavailable for staff to explain to relatives what washappening and for the delivery of poor news. The adultintensive care unit facilities of these areas was of a muchlower standard than the other critical care units due to thelack of purpose built accommodation.

Staff told us that they had sufficient equipment to meet theneeds of the patients. We saw that equipment storage wasan issue on the adult intensive care unit and areasappeared cluttered due to the lack of sufficient storagespace. All equipment was maintained as needed and mostequipment had self-alert indicators when there was a faultor service was needed.

Multidisciplinary working and supportMultidisciplinary working was in place to support patientsacross other areas of the hospital.

We saw the input of therapies on each critical care unit,including physiotherapist, dietician, and occupationaltherapists to promote the health and welfare of patients.


Good –––


We saw that wards and units communicated with eachother to ensure effective smooth transitions of care. The“follow on team” who visited critical care patients who hadimproved and moved on to wards worked with ward staffto support patients and staff told us they appreciated andvalued this input. The management of organ donation wasmanaged within the critical care units and staff were awareof the procedures to follow and the access to contactinformation for transplant services.

Are intensive/critical services caring?

Good –––

Compassion, dignity and empathyPatients and relatives spoke in the highest terms about thestaff and the care they had received. They said staff hadexplained to them at each stage what was happening andtreated them at all times with dignity and respect. We sawstaff reacting calmly to requests for information andshowed the upmost kindness and compassion to patientsand relatives. Relatives told us they appreciated thecontinuity of staff over 12 hour shifts and felt seeing thesame staff again gave them confidence and support.

Patients said they felt well cared for. There was not anoutreach team available in the hospital to visit and assessdeteriorating patients with a view to admission to thecritical care beds. There had previously been an outreachteam but this had become a discharge support team tosupport those patients discharged to medical or generalwards. A system was in place to alert staff to the level ofdeterioration considered to be in need of critical care.There was a system in place for ward staff to contact thecritical care team to review patients whose condition haddeteriorated. Staff told us that the “track and trigger”monitor in place on the wards was effective. There weresystems in pace to review how this alert system wasundertaken and its level of success.

Involvement in care and decision makingPatients and relatives told us that they had felt as involvedas they could be in the decisions about care and treatment.One relative explained how a difficult situation aroundsedation had been handled. They said: “The most awfulsituation was handled as best as it could be”. Theyexplained that the rationale for sedation had beenexplained repeatedly until a clear understanding by the

patient and relative could be established. The relative toldus that doctors and nurses had treated the patient “as anintelligent human being” and how this had beenappreciated.

Trust and communicationPatients and their relatives said they spoke regularly withdoctors and nurses about their relatives care andtreatment. Two relatives told us that they had observed thenursing staff explaining to their relative, despite them notbeing conscious what they were doing and why. The familyfound this comforting. Relatives told us that they had seena doctor soon after their relative was admitted and hadbeen updated regularly.

Relatives told us that staff were “excellent” and “brilliant” atkeeping them informed and updated.

Emotional supportEmotional support was provided both during admissionand after discharge from the critical are units.

A focus group of patients had been developed to discussissues that had arisen following discharge. Informationfrom that was used to effect change on the units. Thisincluded an understanding of why patients rememberedand suffered from bad dreams and how this could becommunicated during admission to emotionally supportpatients while they were in hospital.

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

Good –––

Meeting people’s needsStaffing levels followed national guidelines about caring forcritically ill patients. This meant that for a level threepatient they received one-to-one care. For level twopatients they would share one nurse between two patients.This was because they had less critical care needs.

The matron told of how improvements to practice on thecritical care units had meant that patients were not asdelayed to leave the units. However, the transfer of patientsto wards following an improvement in condition wasdependant on the availability of beds in the hospital.Delayed discharges were audited and the findings reviewed


Good –––


as part of the divisional governance meetings. ICNARC dataalso indicated that for the early part of 2013 there was anincreased amount of delayed discharges out of critical carebeds.

Significant efforts had been made to prevent out-of-hoursdischarges to wards or transfers to other hospitals. In themonth prior to our inspection only one transfer to anotherhospital, out of hours had taken place. This had been aconsidered decision as an urgent bed was needed and thepatient had been previously identified for discharge.

Once a patient was discharged to another ward thedepartment had a follow up nurse who supported criticallyill patients elsewhere in the hospital. Initially they wereseen by the follow up nurse within 24 hours. After that thefollow up nurse would review and assess what support thepatients and nursing staff needed. We received positiveinformation from ward staff about how they found this tobe very supportive. Should a patient be transferred to theChurchill Hospital, the follow-up nurse would contact thefollow-up nurse there, and ensure a continuity of care.

Vulnerable patients and capacityPatients who lacked the mental capacity to make adecision were supported. Staff received training in thesafeguarding of vulnerable adults and showed a goodunderstanding of the Mental Capacity Act 2005 and theDeprivation of Liberty Safeguards. For those patients wholacked the capacity temporarily to make decisions,decisions were made by medical staff in their best interest.This was recorded to include the rationale for the decisionand who was involved.

The cardio thoracic critical care unit was developingdementia care practice and a lead for the role, a band 7nurse, had received training and was cascading thisawareness to other staff. Identification of the differencebetween patients experiencing delirium as part of theircritical care and those patients with a level of dementiawas being classified by the use of a flower indicator. ”Forgetme not” stickers for patients with dementia care needs anda daisy for those patients experiencing confusion werebeing used.

Visits can take place by the hospital chaplain to support thespiritual needs of patients, relatives and staff regardless oftheir beliefs and a 24 hour on call service is provided.

Access to servicesOver 1,200 critically ill adults were admitted to the twoadult intensive care units at John Radcliffe and ChurchillHospital per year. Facilities were available for relatives orcarers to be able to stay close by to the critical care units.We saw that the accommodation for the cardio thoracicand neuro-critical care units were superior to that of theadult intensive care unit. However, all relatives or carersaccommodation included information about what toexpect from each unit, information relating to visiting timesand facilities and how to raise a concern.

Leaving hospitalPatients were discharged with appropriate information. Itwould be very rare for any patients to be discharged homefrom the critical care units. Patients who left the unit forother wards or hospitals had a record of their electronicnotes produced to accompany them. The shift co-ordinatorwould check all discharge processes had been completedto ensure a satisfactory outcome for the patients. Anyissues around discharge would be raised with the staffteam to promote learning. The electronic systems in otherparts of the hospital were not compatible with theelectronic recording on the critical care units. Should thepatient be sent to another hospital, sufficient information(in printed form) was provided to inform the receivinghospital.

The hospital maintained a policy that no patients would betransferred between inpatient areas for non-clinicalreasons between 8pm and 8am. This included transfersfrom ward to ward and transfers to other health providersoutside of the trust. Staff told us that every effort was madeto adhere to this policy and a notification is made to recordwhen these transfers take place. This enables an audit trailof incidents for review.

Learning from experiences, concerns andcomplaintsEach critical care department captured patient feedback.This included results from the “friends and family test”,complaints, and comments. Each unit also requestedinformation via their own questionnaires. We saw that allinformation received had been reviewed and plannedactions to make changes available on notice boards.Comments had been received about noise levels at night.


Good –––


An action seen to address this problem was that ear plugsand sleep masks were made available, bins were beingchanged to be quiet closing, and staff were being madeaware of the need to be quiet at night.

Staff told us that they received feedback from notifications,complaints and patient experience feedback.

Are intensive/critical services well-led?

Good –––

Vision, strategy and risksStaff were clear about the trust vision for the future. Theyexplained they had been involved in the development ofthe vision and felt involved in the strategy and future of thetrust. Some staff felt the executive board were more visiblethan others. Some staff did not know who their divisionallead was or who to contact with any board level questions.

Governance arrangementsThe critical care departments monitored the quality of itsservice. The critical care leads from each department metmonthly. This was an opportunity to discuss any issues andfeedback from complaints, review notifications, or areas ofconcern. The divisional governance meetings wereattended by managers from each unit and there is a plan inthe future for the units to spend some of this meeting timevisiting each unit to expand learning. Risks were alsodiscussed at this time and review of critical are areas whichmay need escalating to the trust risk register.

Leadership and cultureStaff teams from each critical care department were wellled. The matron who oversaw the critical care units wasclear about the development and direction of the units.Unit managers were considered highly by the staff on each

unit who told us they felt supported by the managementand able to make suggestions or raise concerns. Staff toldus that they felt supported by all of the experienced staff onthe units and were able to ask for support or help at anytime.

Board walk-arounds took place and staff felt able toapproach board members at this time to raise anyquestions or views. Medical staff told us that they found theboard supportive to ensuing standards of care weremaintained. Management staff told us they felt listened toan involved in decisions which changed the service.

Patient experiences, staff involvement andengagementStaff felt part of the hospital and wider trust.

Complaints were managed via PALS and staff told us thatthere was communication with families and learning takenfrom outcomes of complaints.

Patient satisfaction questionnaire feedback for July toDecember 2013 was seen and was mostly positive. Areascovered included care, environment and dischargeplanning, actions were planned to address any issuesraised.

Learning, improvement, innovation andsustainabilityStaff we met said they felt encouraged within theirdepartment to be innovative. They were able to attendnational conferences, and had training and developmentsupport. We joined a group of band 7 nurses following atraining session which they were supported to have todevelop and support their practice. We saw emailnewsletters for nurses to keep them updated and signpostthem to training and policy updates.


Good –––


Safe Requires Improvement –––





Information about the serviceThe John Radcliffe Hospital maternity unit serves the localpopulation and the surrounding areas and is part of theOxford University Hospital Trust. The maternity units acrossthe whole trust delivered 8,777 babies in the year from 2012to 2013 and cares for women with acute needs who mayrequire specialist care.

The maternity service is a consultant-led unit. There is adedicated labour suite which consists of 13 delivery rooms,one of which includes a birthing pool and two observationsrooms. There are two dedicated theatres attached to thematernity department. There is contingency to open atheatre in the delivery suite should there be a requirementto close one of the permanent theatres, thereby ensuringtwo theatres can always be in operation. This provides careand treatment to women for elective and emergencycaesarean sections. There is a 10-bedded observation areafor women who are in the immediate post-caesareansection phase of their recovery as well as women whorequire close monitoring, including women receivingantenatal care or postnatal care with complex health needsand are of high risk and having their labour induced. Thereare also three wards providing both antenatal andpostnatal care, and a four-bedded, midwife-led unit whereantenatal, delivery and postnatal care is provided.

As part of our inspection at the John Radcliffe maternityunit, we sought the views of people using the service. Wespoke with 22 patients and their relatives and 24 staffincluding doctors, midwives, consultants, midwiferysupport workers, and other allied health professionals. Weobserved care and treatment to assess if patients hadpositive outcomes and looked at the care and treatmentrecords for some of the patients. We gathered further

information from data we requested and received from thetrust. We undertook interviews, ran focus groups, andlistening 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 also reviewed information regarding their internalquality assurance and compared their performance againstnational data. We used all the information to plan andinform our inspection.

Maternity and family planning

Good –––


Summary of findingsWomen received care and treatment from caring,compassionate, and skilled staff. We received positivecomments from women and their families about thecare and support they received.

The delivery suite had been without a manager for the18 months prior to our inspection due difficulties inrecruitment. Elements of this role were being covered bythree band 7 midwives, but this did not providedconsistency in the management of the delivery suite.Although the delivery suite provided women in labourwith one-to-one care, staffing levels were not alwayssufficient to ensure women received the care andsupport they needed. Recruitment that had occurredwas of newly qualified midwives who needed supportfrom the experienced midwives within the department.This added further pressure to those staff. In additionnewly qualified midwives reported not receivingadequate preceptorship. There were insufficientsupervisors of midwives in post to meet guidance fromthe Nursing and Midwifery Council. There wasinsufficient consultant presence within the delivery suiteto meet national standards, although midwifery staffreported that consultants were supportive.

Despite this the maternity service was effective. Careand treatment was mostly provided in line with nationalguidance, with the exception of a higher number offorceps deliveries and best practice with regards tosupporting new mothers with breast-feeding was notalways followed.

The patients were safeguarded from the risk of abuse.Staff had received training in safeguarding and wereaware of the process to report any concerns. Theseensured patients were not put at risk as appropriatesafeguards were in place.

There were systems in place for the safety of thepatients and staff. There was equipment for the safemanagement of patients which included bariatric tablesin the theatres and beds in the unit. Training andsupport for the staff was promoted to ensure safeworking practices.

Women and their partners told us they receivedkindness and compassionate care from staff, although

the hospital had lower than expected scores in the“Friends and Family tests”. They received sufficientinformation in order to make informed decisions aboutcare.

The maternity unit was clean and staff followed theinternal procedures for hand washing. Hand gels wereavailable at different points and visitors wereencouraged to use them. Staff had completed training ininfection control to ensure women and babies wereprotected from the risk and spread of infection.

The service was responsive to women and their babies’needs. There was cohesive multidisciplinary working;staff commented this worked well with good supportfrom clinicians at all levels which in turn had positiveimpacts on patients care.

There were clinical governance strategies and regularmeetings which looked at development of the service.Staff felt supported within the ward and units; howeverthey told us they felt disconnected from the widerorganisation.

Despite the absence of a manager in the delivery suite,the service was well led. Staff reported that they feltsupported by their immediate line managers and therewas suitable governance processes in place.


Good –––


Are maternity and family planningservices safe?


Safety and performanceWomen and their babies were protected from abuse andstaff were trained to deal with suspicions of abuse. Trainingrecords showed 85% of staff, were trained in safeguardingchildren and vulnerable adults at the appropriate level fortheir role in the department. Staff were aware of the signsof abuse and the appropriate actions and systems forreporting allegations of abuse. Mothers to be wereassessed in the community as part of their antenatal careand information about patients who were at risk wasshared with the staff in the department. A coding systemwas used to ensure this information was not missed andwomen and their babies continued to be safeguarded onadmission.

Information from the risk register showed the trust hadidentified potential security concerns regarding newborninfants and vulnerable adults. As a result an anti-abductionpolicy was developed and agreed in October 2013 by theclinical governance committee.

The safety and wellbeing of patients undergoing caesareansections was protected. The World Health Organization’s(WHO) surgical safety checklist was actively used inoperating theatres. The WHO safety checklist wasdeveloped by the World Health Organization, and requiresall of the theatre team to engage and accept jointresponsibility for ensuring that safety checks areundertaken at each defined stage of the surgicalprocedure, thereby minimising the risk of the mostcommon and avoidable errors occurring. The care recordsfor two patients showed these had been completed.

There was insufficient midwifery staff within thedepartment to meet the needs of all patients. There weresystems in place to divert midwifery staff to the deliverysuite to ensure women received one-to-one care during thecritical stages of labour. However, this involved movingmidwives from other areas of the maternity departmentincluding areas where high-risk patients with complexhealth needs were situated. This left those areas shortstaffed and women and their babies’ needs were notalways met. One ward midwife said they were often left on

their own to care for up to 35 mothers and babies, whenmidwives were diverted to work on the delivery suite. Thehead of midwifery stated that in situations such anothermember of staff would be assigned to help (this wouldgenerally be a maternity support worker not a midwife) butthe midwife would not be left on their own.

On level 7, where there were patients who neededsignificant emotional support as well as ongoing ante andpostnatal care, there was only one midwife and onemidwifery support worker at night. This was not sufficientto ensure that women and their babies received thetreatment, care and support they required. For example,there was a baby who was receiving antibiotic treatmentbecause they were at risk of developing an infection aftertheir birth. This required the baby to have observations oftheir condition every six hours, including temperaturemonitoring to ensure that should an infection occur, itcould be treated promptly. There was a form in placewithin the baby’s notes in order that this monitoring couldbe documented. However, this had not been completed forover 24 hours.

There was a 10-bedded observation ward to the side of thedelivery suite. This ward provided antenatal and postnatalcare to high-risk patients. This included those who hadsevere pre-eclampsia, were having labour induced and hadcomplex health needs, and women who werepost-operative, having had their babies delivered bycaesarean section or those who required surgery followingtheir delivery. There were only two midwives providingtreatment, care, and support to these patients. Thehospital, in monitoring the staffing using their own acuitytool, had identified this as an area where there were notsufficient staff. Managers that we spoke with could not tellus what was being put in place to rectify this.

Although there were specialist breast feeding midwiveswithin the hospital, we saw that women did not receivesufficient support to continue to breast feed their babies ifthey found it difficult. Breast feeding was started on thedelivery suite by midwives. However, midwives reportedthat they did not have time to provide sufficient support tonew mothers to continue breast feeding. This includedhaving time to demonstrate techniques to support thebaby and mother. The trust told us that maternity supportworkers also provided support to women with breastfeeding.


Good –––


There was no manager in place for the delivery suite. Thisrole had been vacant for about 18 months at the time ofour inspection. There had been attempts made to recruit tothis role. However, these had been unsuccessful. Elementsof this role were being covered by three band 7 midwives,over three days a week. The trust told us in addition to this,the head of midwifery was acting down to provideadditional clinical support. Prior to this arrangement twomidwives had been acting up into this role in a job sharearrangement. Although these arrangements were in placethere was a lack of consistency in leadership within thedelivery suite.

A maternity staffing paper to the trust board in May 2013identified that the midwife to birth ratio in the hospital was1:32–1:33 which was outside the national guidance (SaferChildbirth October 2007) which was a minimum ratio of1:28. This resulted in midwives being moved from clinicalareas into the delivery suites to ensure that there wasadequate staffing to ensure safe births. The paper stated:“having considered the national guidance, the financialimplications and the need to provide a safer service, theHead of Midwifery believed the service could currently beprovided safely with a ratio of 1:30. However, if the activityand acuity should significantly increase beyond currentlevels, there would be a need to revisit the staffingrequirements.” Data from January 2014 showed they wereachieving a midwife to birth ratio of 1:31. An update onmaternity staffing to the trust board occurred in October2013 and staffing remains under review.

The national standard for consultant presence on thedelivery suite of the size of the hospital is 168 hours perweek. The hospital was achieving a level of 72 consultanthours per week dedicated to supporting the delivery suitein January 2014. Within the same Maternity staffing paper,there was an aim to increase the consultant presence to120 hours per week which meant an increase in 3 wholetime equivalent consultants. This had not changed sinceMay 2013 when the maternity staffing paper was acceptedby the trust board. There was no information about theactions being taken by the trust to rectify this other thanthe acknowledgement that the level of consultant presenceon the delivery suite required increasing.

The maternity staffing paper also referred to a recent audithighlighting delays in the care of women undergoingInduction of Labour (IOL) and Elective Caesarean Section.This stated “Some women have to wait in excess of 17

hours within their IOL process because of the pressurewithin the service; this is unacceptable.” The staffing levelswithin the hospital have not improved significantly sincethis time. Where recruitment has occurred this has been ofnewly qualified midwives, which has placed additionalpressure on existing midwives within the hospital. Newlyqualified midwives reported that they had not receivedsuitable preceptorship (specific supervision and supportwhich is required to be provided within a nurse or midwife’sfirst year following qualification in order to maintain theirregistration and progress in their career).

There were not sufficient numbers of supervisors ofmidwives (SOM) within the hospital. The role of thesupervisor is to protect the public through good practice.They empower midwives and student midwives to practicesafely and effectively. As supervisors they provide support,advice, and guidance to individual midwives on practiceissues, while ensuring they practice within the midwivesrules and standards set by the NMC. Each midwife meetswith her SOM at least annually. The head of midwiferyreported this was a ratio of one SOM to 30 midwives (1:30).The guidance from the Nursing and Midwifery Councilstates that there should be no more than 15 midwivessupervised by one SOM (a ratio of 1:15).

At the time of our inspection there had been no furtherformal staffing review of the maternity services by thehospital or the trust since October 2013.

Learning and improvementThere were effective processes in place to captureincidents. Staff were aware of how to report incidents if oneoccurred. These incidents were discussed at the clinicalgovernance meetings which occurred on a quarterly basis.A quality, risk, and audit newsletter shared informationwith staff.

The staff on one of the wards told us about their current“topic of the month”. This followed incidents of retainedswab and policies had been developed about the strictmanagement of swabs and an action plan was developedto minimise the risk of recurrence. On the delivery suiteanother example of learning for incidents related to thechange in practice in the drug management of womenhaving an eclamptic fit as a result of high blood pressure.

A senior member of staff told us of specific training whichwas initiated for staff following increase in abruptions (acomplication of pregnancy where the placenta partially or


Good –––


completely separates from the lining of the womb) whichhad been present during the initial assessment of thewomen. Consultants had run training in CTG(cardiotocograph) monitoring of fetal heart rates in order todevelop staff experience in identifying complex issueswhich are easy to miss.

Systems, processes and practicesThere were monthly clinical governance meetings withinthe maternity directorate, and a monthly incidents claimsand complaints group. Unexpected term admissions to theneonatal unit were reviewed in multidisciplinary meetings,and unusual or complex CTG tracings were reviewed on thedelivery suite. These discussed issues arising in order thataction and learning could be identified.

A monthly infection control audit for hand washing wascompleted and the results were displayed to inform staffand visitors to the unit. There was a system for thefrequency of re-auditing depending on the score achievedand this could be as soon as one week. There was clearinformation for the staff about infection control. This meantinfection control was taken seriously and action taken toprotect women and their babies.

Monitoring safety and responding to riskThe hospital had systems in place in identifying risk andensuring patients were in the most appropriate place fortheir care and treatment. Women from surrounding areasincluding Horton General hospital were referred to thehospital for obstetric care. For example women with typeone or two diabetes, or gestational diabetes were cared forhere and were monitored during their pregnancy by aspecialist diabetic midwife. A “silver star” team monitoredall women with diabetes through the ante- and postnatalstages and on admission. This ensured they received careappropriate to their needs and specialist advice andsupport was provided to the midwives.

There was a system in place for the monitoring of severelyill women both during pregnancy and immediatepost-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 showed thesewere not always consistently completed and may impacton the level of care. Action had been taken and these werecomplete in the records seen.

The record for a patient following a post-partumhaemorrhage (PPH) showed records were not fullycompleted. The fluids records were completed but thesewere not totalled up to ensure the input and outputvolumes as required were clear as this formed part of themanagement of PPH.

Arrangements 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 aswell as training in obstetric emergencies such as breechdeliveries and the management of severe post-partumhaemorrhages.

Anticipation and planningThe maternity unit had a comprehensive clinicalgovernance structure in place to record and reportincidents and other concerns. Maternity staffing wasreviewed annually across the trust. The birth rate withinOxfordshire has risen by 18% between 2002 and 2012. Thehospital used Birth Rate Plus for assessing managing themidwifery workforce levels. This is a recognised tooldeveloped for maternity services to assess the staffing levelneeded. This informed the number of midwives requiredbased on clinical needs and risk. Midwifery staffing levelswere reviewed across the trust prior to our inspection andrecruitment was ongoing. Despite this there were notsufficient staff to meet people’s needs.

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

Good –––

Using evidence-based guidanceThere were policies and procedures in place on the trustintranet which staff confirmed they were able to access.


Good –––


The maternity services training policy was available to allstaff at induction. There were also clear procedures andguidelines which were adhered to in relation to thetermination of pregnancy.

The delivery of care and treatment was based on guidanceissued by professional and expert bodies such as theNational Institute for Health and Care Excellence (NICE).Records showed that the department followed specific carepathways to ensure the patients received care appropriateto their needs. On the maternity unit the “immediate careof the newborn guidelines” had been updated to reflectNICE guidance. The trust had introduced the newborn earlywarning score chart (NEWS). The NEWS observation chartwas used to identify any deterioration in a baby’s conditionand reported to the midwife and paediatrician caring forthe baby. This meant action could be taken at an earlystage and appropriate intervention 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.

However, at times NICE guidelines were not followed. Thisincluded when using equipment, for example, forceps orventouse cups to assist and enable delivery. Trust datashowed a higher rate of forceps delivery than expected.Staff said this was due to a particular type of ventousedevice being withdrawn from use by the trust and a lack ofstaff knowledge relating to the alternative. This hadresulted in medical staff reverting to using forceps to assistdelivery. The maternity dashboard showed the trust targetfor ventouse and forceps delivery was 10-15%. The data forJanuary 2014 this was higher than expected in the previousquarter at 16.4%.

The staff used “fresh eyes” system for women who werehaving CTG recordings during labour. This involved gettinga second opinion from the lead co-ordinator on thedelivery suite, usually on an hourly basis, to look at the CTGinterpretation and tracings. This followed good practiceguidance as recommended by the NICE guidelines (2007)ensuring any changes to the fetal heart rate and pattern arenot missed.

The hospital was not accredited as a “baby friendly” sitethrough the UNICEF baby friendly initiative. This is an

initiative set up by UNICEF and the World HealthOrganization, designed to support breastfeeding andparent infant relationships, by working with public servicesto improve standards of care. This provides a framework forthe implementation of best practice by NHS trusts, otherhealth care facilities, and higher education institutions,with the aim of ensuring that all parents make informeddecisions about feeding their babies and are supported intheir chosen feeding method. NICE guidance refers to thisinitiative as a minimum standard. We were told the hospitalwas working towards this and a working group had beenset up to achieve this. However, best practice in supportingmothers with breast feeding was not always followed.Bottle feeding was offered over the use of cup feedingbecause staff did not have time to provide the additionalassistance.

Performance, monitoring and improvement ofoutcomesThe maternity service had achieved CNST level 2 status inNovember 2013. This involved a significant number andrange of audits to be carried out both locally as well asparticipation with national audits. We saw that theoutcome of these audits were discussed at monthlymeetings and action plans developed in order to improvepractices.

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 delivery rate. There was noevidence to demonstrate that the hospital was working toreduce the rates of forceps deliveries.

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. Women reported that they received effective painrelief during labour and as necessary following delivery.

There was evidence that learning from incidents wasmonitored. For example, information from the trust papersshowed changes in practice were implemented for perinealcare. This had resulted in the reduction in third and fourthdegree tears for women during birth.


Good –––


Staff, equipment and facilitiesThe trust risk register report in November 2013 a number ofCTG machines were nearing the end of their service life. Abid had been placed for their replacements. We saw therewere a number of new machines in the department.

Staff told us they had adequate access to equipment andat times they did borrow some equipment from the otherwards. There was equipment for the safe management ofpatients which included bariatric tables in the theatres andbeds in the unit.

There were systems in place for monitoring thetemperature at which medicines were stored, including themonitoring of fridge temperatures. Medicines were securedappropriately.

Following the introduction of newborn early warning score(NEWS); one of the wards had received new monitoringequipment to ensure these were available to babies whorequired them.

The staff were not aware of a policy for equipmentchecking. During discussions with the manager of thetechnical engineer department we were told there was anelectronic database held of all the medical equipmentused in the trust. We heard equipment was not routinelymaintained or serviced according to a fixed annualschedule. An appropriate service schedule was determinedfor items of medical equipment at the point of entry to thetrust. In some cases, the service schedule might involve noroutine maintenance unless a fault was reported to thedepartment. We reviewed the equipment on the deliverysuite and on the wards. We were told equipment was sentfor repair or they were replaced if they were not working.Records of maintenance and servicing were maintained ona corporate database.

The environment was clean and safe with a programme ofrefurbishment.

Multidisciplinary working and supportThere was good multidisciplinary working across thehospital and community maternity services and withinother services in the hospital. Staff felt supported byspecialist midwives responsible for bereavement, breastfeeding, diabetes and also by allied healthcareprofessionals. We noted there was a supportive and openculture and staff felt well supported by the consultants. Onthe delivery suite there was consultants cover on weekdays

between 8am and 9pm. At weekends they were presentbetween 8am-2pm or 9am-3pm and also on call cover wasprovided. We were told there were no issues with juniordoctor and registrar cover for the unit.

Access and support was also available fromphysiotherapists which the midwives said was veryvaluable teaching for mothers. We saw detailed advice andguidance leaflets were available in relation to exercise,driving following caesarean section and general post-natalhealth and wellbeing.

Are maternity and family planningservices caring?

Good –––

Compassion, dignity and empathyWomen and their families were positive about the care andtreatment they had received. They described staff asknowledgeable and compassionate. Some of thecomments included: “the staff are excellent and caring”. Wewere told the staff were welcoming and addressed patientsby their name. We saw consent was sought prior to anintervention.

We observed women’s privacy and dignity beingmaintained within the maternity unit. On the labour warddoors were kept shut and we saw staff knocking prior toentering. On the wards the privacy curtains were used andpatients commented “the staff always make sure thecurtains are closed.” Another patient told us “havingprivacy is not a problem as you can pull the curtains.”

Involvement in care and decision makingWomen were informed and involved in the decision 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 care. Decisionsabout tests for fetal abnormalities and the optionsavailable to the patients were fully discussed. This includeda patient who had elected to have a termination ofpregnancy after the diagnosis of a severe fetal abnormalityhad been made, following discussion and advice from staffin order to assist them to make an informed choice.


Good –––


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. Comments included’ “itwas all discussed at the clinic about my options to havecaesarean section” and “I was reassured about having anepidural when I saw the anaesthetist.” Women were wellinformed about the possibility the birth plan may not befollowed if they required emergency intervention.

Trust and communicationCommunication between the midwives, women and theirfamilies was good. Women and their partners weresupported and able to ask questions. Women said themidwives were very good at listening and providedsupport. They felt they had confidence in staff and trustand communication was good. We observed advice givenover the phone to women and partners, was clear andprovided reassurance.

Staff used a recognised communication tool when taking awoman to the delivery suite from the wards. This ensuredthe communication included the situation; background;assessment and response required were recorded andshared in the interests of the patient.

Women and their partners described their experience ofcare as positive and were complimentary about the careand support they received. Throughout the inspection weobserved staff discussing care, support and changes whichoccurred in relation to the women and their babies. Theseensured women and babies continued to receiveappropriate and effective support and care according totheir needs.

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.

The friends and family test showed 85% of women wouldrecommend their postnatal community service to friendsand family.

Emotional supportArrangements were in place to provide emotional supportto patients and their family in a sensitive manner. Therewas a bereavement specialist midwife and pastoral careservice available to support women, partners and theirfamilies if they chose. There was a separate bereavementsuite facility to provide privacy and support at such difficulttimes. This ensured women, their partners and theirchildren had the opportunity to have private time.

Advice and support for antenatal complications andtermination of pregnancy for fetal abnormality wasmanaged sensitively and staff told us a counselling servicewas available and shared with patients.

Women and their partners were positive about theemotional support they received from midwives andsupport staff. A patient commented they had received“excellent support when I needed help with breast feeding”.Another comment was “the staff are marvellous and theyare there for you.” A breast feeding specialist midwife wasavailable to women to offer practical and emotionalsupport. The trust target for initiating breast feeding wasover 78% and they had achieved 79.7% in the last quarter.

One of the wards had received a grant from the Departmentof Health to develop two new family rooms to supportwomen with mental health problems. This would ensurethese patients receive care and support in appropriatesurrounding to meet their needs.

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 birth planswere developed to meet those needs. There was anobservation ward adjacent to the delivery suite wherewomen were admitted for closer monitoring. Two patientswho had been receiving care in the observation unit said“the care was very good” and “they kept a close eye onyou”. One person was kept informed of the frequency ofblood tests they needed as they were receiving insulininfusion and the dosage was titrated according to theirblood sugar levels.


Good –––


Staff were able to monitor the fetus in labour via telemetry.This meant women could be mobile and active in labourand where desired, could still access the birthing poolwhile continuous fetal monitoring continued. This meanthigher risk women for example those wishing for VBAC(vaginal birth after caesarean section) were notautomatically excluded from using the pool.

Specialist midwives were employed to provide support forthe patients and staff. These included staff with leads rolesin diabetes management in pregnancy, breast feeding,drug and alcohol problems and teenage mothers. Postnatal advice and support was available to assist motherswith incontinence and bowel 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, audio version and in languagesother than English.

Staff said delays in getting a translator could impact 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 visits. This would ensure early booking forthis service was initiated.

Care plans were detailed and contained informationincluding fetal and maternal well-being, diet, hydration,pain control, and mobility. All women had a venousthromboembolism (VTE) assessment to assess their risk forblood clots. Where risks were identified, treatment planswere in place which included anti- embolic stockings.

There was no facility for women to administer their ownmedicines. Staff told us this was due to medications errorsand decision was taken at trust level to remove this facility.The patients we spoke with were not aware they could taketheir own medicines. We received positive feedbacksregarding support and availability of pain control.

Vulnerable patients and capacityThere 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.

Patients who were at risk of domestic violence weresupported and advice was available to them. Staff followed

the care pathway for patients with mental health problemsand were able to access support from externalprofessionals to help and support these patients. A mentalhealth assessment was completed as required.

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.

For mental health patients, the trust had introduced newstickers to act as a reminder for midwives to follow at 28, 32and 40 weeks. This ensured patients were tracked andstrategies put in place to meet their needs.

Access to servicesInformation indicated access arrangements were adequateand there were no issues with access to care. Staff, womenand their partners, confirmed this. Patients told us they feltthe service was good and served the community well.Patients told us they came out of the county and madepositive choices to use the service at the John RadcliffeHospital. The trust had specialist teams of midwives suchas drug and alcohol support and teenage pregnancymidwives which ensured care and support was available towider community and those hard to reach. They heldclinics to provide support and advice to effect maternaland child wellbeing. There was also a good support fromthe community midwives team which ensured womencontinue to receive continuity in their care.

Leaving hospitalThere were appropriate arrangements to ensure safedischarge planning were followed for women and babies.Some patients told us their discharge was planned duringantenatal visits. We observed the discharge process forpatients on different wards and found staff followedprocesses. For patients who lived within the Oxfordcatchment areas, the discharge information were faxed towomen’s GPs and the community midwives at the time ofthem leaving hospital. This ensured information wasshared appropriately and follow up appointments were notmissed.

For patients who came from outside the county, themidwives initiated a phone discharge process and followedthese by letters sent by post. At weekends staff telephonedthe community teams to ensure they were aware ofpatients who had been discharged. Patients were alsoadvised to ring the maternity unit if they did not receive a


Good –––


visit from their midwives within a specific timeframefollowing discharge. This ensured mothers and their babieswere seen by their community midwives as the appropriatetimes and continued to receive acre and treatment/support as needed. Take home medicines were dispensedfrom the pharmacy and staff said this at times did causedelays on discharge. Other advice such as wound care andperineal care and “your recovery after childbirth” wereissued to the patients.

Learning from experiences, concerns andcomplaintsConcerns and complaints were discussed monthly at thewomen’s services clinical governance meeting and alsoreviewed by the risk manager. We received positivefeedback from patients about the care and treatment theywere receiving. They were aware of the procedure to raise aconcern. Staff told us they would speak with theirimmediate managers if they had a complaint or concern,but said they would not raise concerns at trust level.

There 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 delivery suite. Patients could alsocontact the Patient Advice and Liaison Service (PALS) if theyneeded support about raising concerns. This informationwas displayed and available in different formats andlanguages which supported patients’ diverse needs.

Complaints were collated on a quarterly basis and lookedat any recurrent themes and root causes. This waspresented at the maternity quality meeting and women’sservices clinical governance meeting. Changes wereintroduced which included appointing a breast feedingspecialist midwife.

Are maternity and family planningservices well-led?

Good –––

Vision, strategy and risksThe trust newsletter for January 2014, described thedevelopment of a teenage and pregnant parent (TAP)service to provide support to women under 20 years of age.

This service was aimed at teenagers to provide informationand guidance on pregnancy, birth and antenatal checkswere also provided. This initiative was to encourage themto use the service and support this age group.

There was effective teamwork in the department, and staffwere considerate there was effective communicationbetween all grades of staff. There was a process of lookingat risks and these were discussed at the monthly clinicalgovernance meetings. These were multidisciplinary teammeetings and actions on risks were discussed fromprevious month and were either closed or taken forward forfurther reviews. New risks were discussed and designatedstaff were allocated to take action within a set timescaleand feedback at the next meeting and added to the riskregister. Progress against actions was reported. They alsoconsidered how these risks may impact on otherdepartments.

The clinical governance lead and risk manager met on aweekly basis to review unplanned neonatal admissions andadmission to intensive care unit. They monitored anytrends such as the increase of grade 2 pressure ulcers forwomen following caesarean sections. Actions plans weredeveloped including review of mattresses and position ofwomen in recovery. There was a strategy in place forescalation of risks and staff felt confident in raising them.

Governance arrangementsGovernance 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.

This included sharing of good practice and learning fromadverse events and occurrences which was shared amonga multidisciplinary team. The maternity unit wasrepresented at governance meetings and feedback to staffwas provided.

Leadership and cultureDecisions about care and treatment were taken at theappropriate level. There was a lead co-ordinator on each


Good –––


ward who was available to co-ordinate the overallmanagement of the unit. While the delivery suite did nothave a manager, they had a midwife who undertook aco-ordinating role for each shift.

The staff said there were good working relationshipsbetween the medical staff, midwives, and otherprofessionals. Staff received good support from theirimmediate manger and were comfortable to raise theirconcerns at local level. Senior management and other staffwe spoke with were clear about the trust vision and values.Staff told us they were satisfied with the local managementarrangements, but they felt disconnected from theorganisation and trust board. Comments from staffincluded “[we are] all looking out for each other”. The staffwere confident in calling out the on-call consultant andsaid they always received a positive response.

Patient experiences, 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 thempositively and provided care and support according to theirneeds. However, the friends and family test scores werequite low: Only 34% would recommend the hospitalantenatal service to friends and family and 64% wouldrecommend the post natal care The highest score was forthe labour ward/birthing unit where 68% of patients saidthey were extremely likely to recommend the service tofriends and family if they needed similar care.

Staff had regular staff meetings and received informationform newsletter which were sent out quarterly. The wardmeeting minutes from February 2014 provided staff withupdates on care and changes in practices and e-learning tobe completed. Staff commented the meetings were goodand they were able to raise any issue such as staffing.

Learning, improvement, innovation andsustainabilityStaff received regular appraisals and this was anopportunity to discuss their personal development. Theappraisal rate in maternity was 92.3%. All midwivesreceived resuscitation training and were reminded theyneeded to complete the e-learning part of this prior toattending the training. This included basic life support forthe midwife support workers. In addition, midwives anddoctors all received training in the management ofobstetric emergencies

Staff were involved and contributed to various studies withOxford University which included fetal growth, eclampsiaand vitamin D studies which would have a direct impact onfuture management of patients.

The trust quality and risk audit highlighted the currentproblem with providing tongue tie service for babies. Thiswas currently 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 serviceChildren’s services in Oxford are based at the children’shospital on the John Radcliffe site. This is a purpose-builtenvironment. The hospital provides care for children frombirth to 16 years of age. There is dedicated children’soutpatients department although some clinics do takeplace in other areas of the hospital such as the ear noseand throat (ENT) department. Services provided includecardiorespiratory, gastroenterology, acute medicine,haematology, oncology, neurosciences, specialist surgery,general surgery and neonatal surgery. There is also apaediatric intensive care unit (PICU), paediatric highdependency unit (PHDU) and a neonatal intensive care unit(NICU). Adolescents are catered for within their owndedicated ward. There is also a ward which is dedicated toproviding care to adolescents. The hospital has play areasand a school to cater for all children’s needs. The children’shospital also has facilities for families.

Summary of findingsWe visited all the wards in the children hospitalincluding the PICU, the PHDU and the NICU. We spoke to45 members of staff. This included health care assistants(HCAs), student nurses, staff nurses, midwives, seniornursing staff, doctors, registrars, consultant, andanaesthetists, operating department practitioners,nurse practitioners, administration staff,physiotherapists, and play specialists. We also spoke to14 parents and relatives, three children and two youngpeople.

Parents, children, and young people were positiveabout the care and support their received. They told usthey were kept informed and involved in makingdecisions. Staffing levels were considered whenmanaging the number of beds available to be used. Thetrust was aware of areas were additional staff wererequired and they were actively recruiting to theseareas. Staff told us they felt supported and the children’shospital was a good place to work. There were systemsin place to ensure children at risk of harm or consideredto be of concerns were identified and protected if seenin the hospital. Staff were aware of how to reportincidents and this information was monitored, reviewedand learning shared with the staff. There was anestablished governance system in place that includedmonitoring complaints, incidents, out comes fromaudits and the adherence to national guidelines. Youngpeople’s opinions and input was actively soughtthrough the Young People's Executive.

Services for Children & Young People

Good –––


Are children’s care services safe?

Good –––

Safety and performanceSystems were in place to ensure the safety of the childrenon the wards. For example, areas were secured with swipecard access for staff and an intercom system for others. Weobserved staff confirming the identification of people at thedoor and checking with them the purpose of their visit. Allstaff were wearing picture identification. Children had twoidentification wrist bands in place. We witnessed staffchecking the child’s identification before theadministration of medication and on transfer to theatre toensure the right child was receiving the treatment. Weobserved check lists being completed before and duringthe transfer of patients to the operating theatre, intorecovery and back to the ward. The purpose of thesechecks being to ensure the correct person received thecorrect procedure.

All the staff we spoke with were clear about their role inreporting accidents and incidents. There were 54 incidentsin the children’s hospital three considered to have causedharm but were not serious The staff survey in the children’sand women’s division showed one percent reporting theyhad witnessed an error that could cause harm which wasnot reported. Ninety eight percent of staff who respondedto the survey said they were encouraged to report errors.There was an established system in place to providefeedback to staff about incidents. These including internalemails at ward levels which identified trends and actions.Incidents were also discussed at the children directorategovernance meetings. This was evident in the minutes fromthese meetings that we reviewed. One member of staff onthe NICU told us about changes made to the way one typeof antibiotic was administered following an incident. Theyconfirmed that they had learned about the change throughemails and that as a result of the incident there had been achange in policy on the unit.

There had been a recent incident when the number ofpatients on the PICU was above capacity for the staffinglevels. The increased number of patients on the PICU hadbeen reported using the Datix reporting system. Wereviewed the information and found the correct escalationprocedure had been followed. A team approach had been

taken to address the issue. A review of occupancy withinthe children’s hospital was undertaken, patients that couldbe, were discharged home which freed beds on the wards.This meant children from PHDU could be transferred to theward, and patients from the PICU could be moved to thePHDU. By the end of the day the situation had beenresolved and there was additional bed capacity within thechildren’ hospital.

Systems, processes and practicesThere was good oversight of bed capacity in the children’shospital. The bed manager under took regular rounds tocheck bed capacity and staffing levels. It was clear fromdiscussion with staff that the number of staff wasconsidered when establishing the number of bedsavailable. At the time of our visit four wards were running atreduced capacity due to staffing levels.

Steps had been taken to help control the risk of the spreadof infection. All areas we visited were found to be clean.Personal protective equipment, such as gloves and aprons,was available and staff were using these to help prevent therisk of the spread of infection. We observed there werehand-washing facilities available and accessible as washand gel. All the staff were observing the hospital’s “barebelow the elbow” policy. We observed staff cleaningequipment and saw that clean equipment was labelled toidentify it as ready for use. Side rooms were available in allareas to prevent the spread of infections. A parent whosechild had an infection told us toys were provided whichwere washed before being given to other children. Stafftold us that cleaning staff were available 24 hours a day todeep clean side rooms if there were concerns about the riskof infection.

There were systems in place to safeguard children. Atraining programme was in place with three levels oftraining which reflected staff roles in the hospital.Information for the trust showed that as of November 2013,85% of staff had completed level 1 training, 80% level 2 and76% level 3, plus 69% in midwifery. This was below thetrust’s target of 95% compliance. All the staff we spoke towere aware of their responsibilities to safeguard childrenand had completed training at the appropriate level.

There was a lead nurse and a named nurse for children’ssafeguarding. There was also a named midwife and nameddoctors for children’s safeguarding at the hospital. Staffconfirmed they were available to support them. There wasan established system for identifying children on the at risk


Good –––


register or of concern on the hospital’s electronic recordssystem. We saw this included information about the socialservices team working with the family. We were told thiswas accessible throughout the trust and this was confirmedby staff on the wards. A printed copy of this informationwas also sent to the emergency department. There was amonthly safeguarding children’s forum where cases werediscussed to ensure learning. Any learning was furthercascaded using a document called “at a glance”.

Learning and improvementThe trust had taken action to reduce the risk of harm fromtissue extravasation incidents. This is when fluid from anintravenous infusion leaks into the surrounding tissue. Wesaw that infusion sites were checked to ensure earlydetection of any extravasation. We saw that wereextravasation injury occurred an investigation wasundertaken. The aim was to review the care given and toestablish if any changes in care practises were required toreduce the risk of these incidences happening again.

Minutes from the children’s directorate quality committeemeeting showed that complaints, critical incidents, “DoctorFosters” alerts, mortality, outcomes from audits andnational guidelines were discussed and the risk registerreviewed. These discussions included information onlearning and action taken.

Monitoring safety and responding to riskThe 2013 to 2014 NHS standard contract for paediatricintensive care states “children requiring continuous nursingsupervision, and who may need ventilator support(including CPAP) or support of two or more organs systemsrequire 1:1 nursing”. We were told that the PICU was fundedfor eight beds. The children’s critical care workforce plan for2013 to 2014 showed nine registered nurses per shift whichincluded one shift co-ordinator. We reviewed the staffingrota and allocation diary for the PICU for the 36 days priorto our inspection. While during that period there was onlyone occasion when the occupancy level went up to andabove eight patients, at no time was there enough staff onduty to open all eight beds for patients requiring one toone support. The bed manager told us that to manage this,the unit was only open to provide care in six beds.

The trust had acknowledged that there were challengeswith staffing both the PICU and the NICU. Informationprovided by the trust showed that the NICU had a budgetfor 169 staff although there were only 127 in post, with 25members of staff either on maternity leave, about to start

maternity leave or on sick leave. In addition there were 34vacancies for nursing staff and health care assistants. Theaim was to staff the unit areas (low dependency, highdependency and intensive care) in line with nationalguidance. When we reviewed the staffing rota for the NICUfor the five days prior to our inspection we saw that agencystaff were regularly used and some staff worked overtime inorder to staff the unit. On occasions staff from in differentareas of the NICU would support each other and some stafffrom the PICU and PHDU would also be flexible and movebetween units. The trust was actively undertaking afocused recruitment drive for the NICU in an effort toincrease their staffing levels. In the meantime action wasbeing taken to maintain safe staffing levels.

On the wards staff told us they had enough staff and whenthere were issues with the staffing levels or staffing skill mixthere was an escalation policy to follow. We were told thatbeds could be closed if extra staff could not be located.

Information provided by the trust indicated thatconsultants were employed to fill existing posts in all areasof the children’s services. Although a business case hadbeen submitted for two to three more generalpaediatricians. The PICU was covered by three locums andthree full-time consultants. Middle-grade medical postswere filled by specialist trainees and grid trainees in mostspecialties though we were told there were some gaps inmiddle-grade doctor appointments. There was no evidencethat this was a concern or impacting on outcomes.

An orthopaedic consultant told us that they had noconcerns about the number of nursing staff or the skill mix.A senior staff nurse on the paediatric surgical ward told usthat they were confident that the ward was safe with seniorstaff acting as coordinators on shifts.

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

Good –––

Using evidence-based guidanceWe saw that guidance, policies and procedures were inplace and were regularly reviewed to ensure they remainedin line with current best practice. We reviewed the policiesand procedures for the paediatric medical department andthose on the NICU and found this to be the case.


Good –––


There were two sets of guidance relating to the care of thecritically ill child for the PICU and there was some confusionas to which was the correct set to be used. One set hadbeen developed with the Southampton Hospital as part theSouthampton/Oxford Retrieval Team agreement. Thesewere found to be current and in date. We were told thatthese were the ones that should be used and that theothers would be removed.

There was an established system to review and monitorcompliance with National Institute for Health and CareExcellence (NICE) guidance. We reviewed the results of areview of compliance with the use of sedation in childrenwhich had been conducted by the trust. Areas ofnon-compliance had been identified, action plans put inplace, monitored and a re-audit conducted which hadshown improvements. The children’s and women’sdivisional quality report for December 2013 indicated that10 sets of guidance had been reviewed and the trust wascompliant with all bar one. This related to epilepsy inchildren and young people. A paper had been drawn up toaddress these issues.

Children and their families told us that their pain wasassessed and they received timely pain relief. A mother of ababy on the surgical ward said “there was excellent painrelief when needed.” A young person told us there were noproblems with getting pain relief. Patient records showedthat a pain score chart, devised specifically for use withchildren, was being used. We saw in one child’s records,that following surgery their pain was assessed andmonitored in the recovery area and then on return to theward.

There was a system in place to support staff in identifyingwhen a child’s condition was starting to deteriorate toenable early intervention to ensure that care needs couldbe effectively managed. This included transfer to thecritical care facility if required. Records showed that apaediatric early warning scoring system (PEWS) was in use.However, there was no paediatric critical care outreachteam to support staff in the management of deterioratingchildren. We were told a paediatric critical care outreachteam had been a piloted. As a result of this it wasestablished that the current PEWS tool was not ideal for allsettings and patient groups. Therefore, two further projectshad been commissioned: one was to explore unplannedadmissions to PICU/HDU to review the notes and PEWS tosee if deteriorating children requiring critical care were

identified appropriately. The second project was to trial arange of PEWS tools to assess their suitability. There was notime frame for these projects to be completed. Thisdemonstrated that the trust was reviewing the use ofnationally-recognised tools to ensure that were meetingthe purpose for which they were designed. In the interimstaff on the PHDU told us that they responded to requestsfrom the ward staff for advice.

Play specialist were involved in ensuring that childunderstood what was happening and why. This processincluded the use of toys, models of equipment andpictures. A young person told us that they had been fullyinformed and involved in making decision about their careincluding consenting for their operation.

Multidisciplinary working and supportIn all areas we found that multidisciplinary team workingwas effective. For example the physiotherapist on the PICUtold us that cover was available 24 hours a day. They saidthat there was good communication via themultidisciplinary meeting held each morning. A motherwas complimentary about staff and their liaison with thehome care team. We observed good multidisciplinaryworking with the anaesthetist, operating departmentpractitioner and nurse practitioner working together tocalm and prepare a child for theatre. There was a relaxedapproach with the child involved in the discussion. Thishad a positive outcome with the child laughing whentransferred to the anaesthetic room.

The handovers that we observed were multidisciplinarywith staff listening to each other. For example, on the NICUwe saw an open discussion with everyone involved.Nursing staff were involved in the handovers and wardrounds although we did not see any nurse on the medicalward handover.

There was multidisciplinary working to safeguard childrenin the hospital and in the community. Data and informationwas shared with the paediatric liaison health visitor in thecommunity, link social workers and school nurses.

Staff, equipment and facilitiesAll new members of nursing and administration staffattended a trust induction and an induction to their mainarea of work. How this was managed varied fromdepartment to department. On the NICU there was anestablished pattern with staff working in the differentnurseries, completing competencies and progressing to the


Good –––


next nursery at a pace agreed by them and their mentor.This meant their skills and knowledge were considered aspart of the allocation of work. One experienced more seniormember of staff felt that their induction had not met theirneeds, although they had received some support from theunit educational lead. A new staff nurse on the PICU saidthey had felt well supported and had had a good mentor.An administrator told us that their induction had includingtraining on the use of the IT system which was key to theirrole.

Staff were clear about the trust expectation for them tocomplete mandatory training. Many staff told us that theydid this at home in their own time. On two wards we weretold by staff if they produced evidence that they hadcompleted all their mandatory training during their annualappraisal they were then given time back. Nursing staff toldus that they were further supported with developmentaldays either as teams or according to their grade or role.Staff were trained in either basic or intermediate children’slife support, with medical staff and staff in the intensivecare areas receiving European paediatric advanced lifesupport training.

Medical staff confirmed they had an educational supervisorand clinical skills supervisor. A Registrar told us that theyfelt well supported.

Staff told us that generally equipment was available whenthey required it. We reviewed a selection of equipment andfound that electrical equipment testing dates varied,according to the labels on the equipment, with the oldestbeing 2002 and the most recent being January 2014. It wasnot clear when equipment had last been serviced althoughequipment was labelled with barcodes. Monitors in thePICU were on the risk register as they were no longermanufactured and if they broke would need to be replaced.We checked the emergency equipment on three wards andfound that it had been checked and all equipment wasavailable according to trust policy.

Are children’s care services caring?

Good –––

Compassion, dignity and empathyAll the parents we spoke to were positive about the caringand supportive nature of the staff. They said the whole

family was well cared for and they were kept informed ofand involved in making decisions. In the NICU one mumsaid “they have encouraged me to help with [my child’s]care and they are thoughtful ensuing that my dignity andprivacy is considered when we are having ‘skin to skin’time.” We observed caring interaction between patientsand staff and parents and staff. A parent on Robins wardsaid they received an excellent service from the team. Asecond parent was equally as positive saying they hadbrilliant care. A third parent told us that they feltcommunication was very good with the medical and thenursing teams.

Staff told us there was a very good chaplaincy team whooffered support to both families and staff where hard tohear news was given and or a child died. Information fromthe mortality and management meetings showed thatfamilies were involved in making choices and difficultdecisions. They also demonstrated staff showed a caringapproach with staff being complimented for their approachin sensitive and difficult situations.

Involvement in care and decision makingWe followed a child and parent through from the ward totheatres and back to the wards. The parents were enabledto be with their child until they were asleep. We saw thatgood humour was used to relieve the child’s anxiety andthe while process was smooth and completed withoutincident. The parent was also able to meet their child in therecovery area.

We reviewed a sample of responses to surveys for Kamransward and the PICU. Results demonstrated that parents feltthat they were given enough information to understandwhat was happening and felt that they were involved inmaking decisions.

Emotional supportPlay specialists were available in all areas although theywere not available all of the time. One play specialist toldus that they worked with the psychologist, teachers andnurses to ensure that distraction and developmental playwas prioritised. We saw that play was used to help childrenunderstand their treatment and to prepare them forinvestigative procedures and operations. Parents werepositive about the support and input from the playspecialist.

A mother on the PICU told us they were involved as muchas they wanted to be in their child’s care. Over the four


Good –––


weeks prior to our inspection they had felt supported.Another mother, on the surgical ward, who had somehealth challenges of her own, told us the staff were carefulabout considering her needs as well as those of her child.She commented that she was very happy with the surgeon,who explained everything well and would not hesitate torecommend the ward to others.

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

Good –––

Meeting people’s needsA hospital school supported children to continue theireducation when in they were hospital. This was seen to beparticularly important to the young people on theadolescent unit.

The adolescent unit, a facility designed to meet theirneeds; it was managed inclusively and provided care andtreatment for young people from all specialities. Nursingstaff were clear that they could not be an expert in all areasand actively sort guidance and advice from theircolleagues.

In response to an increased demand on beds the trust hadlooked at other ways of ensuring that children receivedtheir treatment. For example, the trust had arranged forchildren who were well but required physiotherapy, to stayat a local hotel rather than using a bed in the children’shospital.

In the months prior to our inspection, the children’s clinicaldecision unit had moved to be closer to the A&Edepartment. We were told this enabled an “ambulatorycare approach” for children booked to return for a followup to their attendance at the children’s emergencydepartment. The unit also provided 24-hour observationfor some children. The move had also opened up morespace on one of the wards, which after the recruitment ofnew staff would be utilised for paediatric medical patients.

Parents were positive about the facilities available to themincluding accommodation for them to stay and access toparking, although it was acknowledged this was a finitefacility.

Access to servicesSome parents expressed concerned about the number ofdifferent days they had to attend the hospital to seedifferent specialists and said this was not co-ordinated.One family had faced some difficulties when they returnedhome to another county with no after care arranged. Whileparents were positive about their outpatient departmentexperiences and the care they received they raisedconcerns about the time they had to wait.

There was a clear policy in place for the escalation ofconcerns relating to staffing levels. We saw from recordsseen that this system had been implemented.

Learning from experiences, concerns andcomplaintsThe trust monitored and analysed complaints frompatients in children's services. Information indicated 0.08%of patients who used women and children's services acrossthe trust complained in the year prior to our inspection.

We reviewed information relating to six complaints whichwere included in the divisional quality report for children’sservices. Where the complaint had been up held actiontaken to prevent re-occurrence was included in the report.This demonstrated that complaints were taken seriouslyinvestigated and when required action was taken. In oneinstance, where a child’s surgery had been cancelled, anapology was sent along with a new date for the operation.

We saw from the records of meetings that the loss of a childwas discussed at multidisciplinary meetings including anylearning from the events.

Are children’s care services well-led?

Good –––

Vision, strategy and risksStaff throughout the children’s hospital were clear aboutthe trust’s values and vision. New members of staff told usthat this was included in their induction. Staff felt that thevalues were demonstrated in the work they did every day.Staff at all grades told us the appraisal system was in theprocess of being amended and rolled out and this was tobe more values based. Staff involved in interviews wereaware the trust had implemented a values based interviewto recruit new staff.


Good –––


Risks inherent in the delivery of safe care for children wereclearly identified on the hospitals risk registers. On thedivision risk register for children’s and women, there was anentry about the 24-hour management of paediatric airwaysduring paediatric resuscitations and paediatric trauma.This was because of a reduction in the number of medicalstaff confident in dealing with children's airway problemswhen children were admitted to areas outside of thechildren's directorate. The airway pager holder may be withan anaesthetised patient in theatre and unable to attend.We saw that a clear algorithm had been created andcirculated which identified who should attend in thesesituations and the escalation process if the pager holderwas unable to attend.

Governance arrangementsThere was a system in place for the monitoring ofperformance and risk. We reviewed the children’s andwomen’s divisional quality report for December 2013. Thisstated that the report sought to enable the clinicalgovernance committee to monitor the implementation ofclinical governance activities within the division. The paperwas relevant to two strategic objectives. Firstly, to providehigh quality, efficient and innovative core services thatmeet the needs of the local patients and the challenges ofthe local health community. Secondly, to providedemonstrably excellent clinical outcomes and indicators ofpatient safety. Information included in the report related topatient experience; where positive feedback was shared. Italso included information about incidents and complaints.There was additional information on compliance with NICEguidance, safeguarding, medicines audits, and staffing.

Leadership and cultureStaff told us that they felt supported by more senior staff.One of the registrars said that they felt well supported, withgood relationships between trainees and consultants andbetween specialists. A consultant told us they felt there wasgood team work between specialities. They also said thatthey felt the directorate and the division was responsiveand that the department was well led.

Newly appointed nursing staff and health care assistantstold us that they felt well supported, received training toundertake their role and that supervision was available. Astudent nurse on the day care unit said that mentorshipwas good and supervision consistent with all staff willing to

answer questions. A staff nurse on the NICU told us that“generally the relationship amounts the staff is brilliant,everyone is supportive of each other, and they wouldrecommend it as a place to work.”

Patient experiences, staff involvement andengagementChildren and young people were involved in decisions andtheir views obtained through the hospital’s Young People'sExecutive (YiPpEe). The trust had actively engaged withchildren, young people and their parents and carers. Forexample, A set of posters were created by the YiPpEe, toraise awareness of the standards of care and values,pertinent to younger patients. These were created usingimages created captions also written by the young people.Records of meetings also showed that members had beeninvolved in obtaining feedback from their peers and in areview of the menu.

We saw from questionnaires that feedback was soughtfrom families using the children’s hospital about the carethey had received; the information they had been providedwith; the way they were treated and the environment.Those we reviewed were generally positive. Whereimprovement could be made these had beenacknowledged for example one comment was “internetand phone connection would be helpful.”

The staff survey from the children’s and women’s divisionshowed that staff felt the service was well led: 67% of staffwho responded to the survey felt that managers acted ontheir feedback and 66% said that team members met todiscuss the team’s effectiveness.

Learning, improvement, innovation andsustainabilityWe were told that all staff required an annual appraisal.Survey results showed that 71% of staff in the children’sand women’s directorate had received an appraisal. All thestaff, who we asked, bar one, confirmed they had receivedan annual appraisal. Staff were positive about this and toldus that their appraisal included a discussion aboutdevelopment and learning needs. A staff nurse on NICU wasparticularly positive of her experience and as a result wasundertaking a neonatal course with support from staff onthe unit. A new administrator told us that she was workingher probationary period and would have a review at threeand then six months.


Good –––


Safe Good –––





Information about the serviceEnd of life care services were provided by the hospitalbased specialist palliative care team which included aspecialist consultant and specialist nurse practitioners.This team were available to provide face to face supportand advice to hospital staff from Monday to Friday duringworking hours. Out-of-hours, 24-hour telephone supportwas available from specialist palliative care staff based atthe Michael Sobell House Hospice. The hospice is locatedat the Trust’s Churchill Hospital site.

The wider specialist team included allied healthprofessionals, a psychiatrist, bereavement and chaplaincyservices. The specialist team provided support with end oflife care in 30% of the 2,300 deaths per annum at thehospital. Patients were seen by the specialist palliative careteam when they were already known to palliative careservices or when they were referred to the service by wardbased doctors or nurses. A palliative care link nurse systemwas in place which linked identified ward nurses to thespecialist teams.

We visited five ward areas where patients regularly receivedend of life care including the Emergency Assessment Unit,and four medical wards, including two short stay wards. Wespoke with 17 members of staff in a range of roles fromclinical support worker and junior doctor to lead membersof the specialist palliative care team. We spoke with fourpatients and relatives, observed care and treatment beinggiven to people and looked at four care records. We alsoreceived comments from people at our listening events.End of life care for children was inspected under children’sservices.

Summary of findingsPatients received safe and effective end of life carebased on evidence based guidelines, nationalstandards, and protocols. Staff were caring andmotivated. They demonstrated commitment to meetingpatients’ end of life needs and to supporting patients’relatives at this time. A specialist palliative care teamwas based in the hospital and provided advice, trainingand support to hospital staff from Monday to Friday.24-hour specialist advice was provided by staff atMichael Sobell House hospice, based at the trust’sChurchill Hospital. The hospital palliative care teamwere part of a wider specialist team who workedcollaboratively across the Trust’s four hospital sites andin the local community. A member of the team was theNational Director for End of Life Care and chair of theLeadership Alliance for the Care of Dying People.

Feedback from patients receiving end of life care, andtheir relatives, was positive. They were well informed,had been asked what was important to them, and wereinvolved in decision making. They told us that staff weresensitive to their needs and treated them as a wholeperson.

End of life care

Good –––


Are end of life care services safe?

Good –––

Safety and performanceThe trust participated in a large national audit of end of lifecare in acute hospital trusts in May 2013 which includedaudit of recognition of the dying patient, patient records,and people’s experience of the service. The results of thisaudit which would provide external comparative data andbenchmarking information were awaited by the trust. Noperformance data regarding end of life care at the JohnRadcliffe Hospital was available at the time of theinspection.

Learning and improvementAll staff said they were able to report concerns andincidents, most said they would escalate these directly totheir line manager. More senior staff told us how they usedthe Trust’s incident reporting system to capture risks andescalate concerns. Staff were not aware of written guidancefrom the trust about incident reporting requirements, or ofany reporting requirements that were specific to end of lifecare. Staff decided which incidents they reported,sometimes with guidance from a more senior staffmember. We found that lack of specific reportingrequirements for end of life care meant that opportunitiesfor learning and improving standards in this area may belost.

During the inspection we learned of an incident whichoccurred on a medical ward at the hospital in 2013, wherethe prescribed medication for a person receiving end of lifecare had not been given due to a syringe driver failure. Stafftold us that syringe drivers used for pain and othersymptom control during end of life care were routinelychecked every four hours. On this occasion the staffmember was alerted to the patient’s distress by familymembers and “as required” pain relief was administered.Staff administering the “as required” medication failed tocheck that the syringe driver was working as expected atthis time and this was not noted until later. The patient’ssafety had not been compromised in this case but it was aconcern that “as required” medication was administeredwithout first establishing what medication the patient hadalready received.

The incident had been escalated to the matron by the wardsister and was addressed on the ward concerned, but wasnot entered into the Datix reporting system. This incidentinvolved a newly qualified staff member and anexperienced staff member. The staff involved receivedfeedback about the incident and learning was shared withthe ward team. As this incident had not been reported onDatix, or escalated beyond the ward matron, theopportunity to identify wider learning needs and to reviewthe effectiveness of syringe driver safety checks had beenlost to the wider organisation.

Once in the incident reporting system, incidents wereescalated according to their impact and level of risk. Thismeant that unless a major incident occurred the responseto the incident would be managed within the directorate itoriginated from. The Datix system could be interrogated toidentify trends, which could then be reported on. Widerlearning in the trust was communicated in the team briefwhich is an internal briefing for staff. Staff told us aboutchanges to pressure area care that had beencommunicated via the team brief but did not have anyexamples of improvements that were specific to end of lifecare.

As responses to complaints and incidents were generallymanaged within directorates this meant that commonthemes relating to safety and quality of end of life careacross the trust may not be identified. Senior members ofthe specialist palliative care team did not know the scale ornature of complaints/ incidents relating to end of life careacross the hospital or the trust. The specialist palliativecare team were located in the surgery and oncologydivision and were not informed of incidents or complaintsinvolving end of life care in other divisions. This wassignificant as this team provided all teaching in end of lifecare to the ward-based palliative care link nurses andjunior doctors across the trust. Training in end of life carewas not mandatory for nurses or support staff, but learningwas disseminated through the link nurse role. Thisincluded updates to equipment used, including syringedrivers.

Staff told us that there was good team support on the wardareas after patients had died. This included discussion oflearning points such as response to emergencies. Staff

End of life care

Good –––


expressed no concerns about patient safety in relation toend of life care as they felt supported by the palliative careteam and had good access to specialist advice. They feltthat this support had a positive impact on end of life care.

Systems, processes and practicesStandard operating procedures that reflect national andprofessional guidance had been established for thespecialist palliative care multidisciplinary team. Thehospital specialist palliative care team were based on siteand supported staff in providing end of life care fromMonday to Friday during working hours. Staff knew aboutthe team and how to contact them and information aboutthe service was displayed on posters in ward areas. Out ofhours specialist support was always available bytelephone.

Staff had access to clear information that enabled them todo their job effectively. Specific guidance for end of life carewas accessible via the trust intranet. This included detailedguidance and documents to support advance careplanning, discharge home for end of life care, pain andother symptom management. This was backed up by endof life resource packs containing hard copies of thesedocuments, available on each ward and by support fromthe palliative care team. This resource pack was notavailable on all wards we visited. This meant that guidanceand policies may be difficult for new or temporary staff tolocate and refer to as they may not have intranet access.

Staff had received appropriate mandatory safeguardingtraining and demonstrated awareness of their role inreporting concerns and protecting people. Senior staff wereaware of the systems in place to protect people within thehospital and how to access these. We heard an example ofhow a former patient with a learning disability had beenprotected. Requirements around resuscitation training andpractice were clearly set out in the trust resuscitationpolicy. This included appropriate arrangements for Do NotAttempt Resuscitation (DNAR) decisions.

Monitoring safety and responding to riskFour-hourly checks were carried out by nurses whensyringe drivers were being used to administer medicationto patients. This included checking the dose deliveredagainst the dose remaining in the syringe and checking thebattery life of the syringe driver. Nurses described verbaland non-verbal cues they used and feedback they soughtfrom patients and/or their families, to assess the impact ofmedication on the patient. An early warning system, known

as “track and trigger” was used to identify deterioration inan individual patient’s condition. (Early warning systemsuse vital signs including pulse, blood pressure, respiratoryrate and temperature to assign a risk score to the patient’scondition so that changes and risks can be readilyidentified and acted upon). Nurses told us that this systemworked well as everyone understood the significance of thescores obtained. Guidance in the use of the early warningsystem was available on the trust intranet under the policyfor identifying and responding to acutely ill inpatients.

Individual patient risks were assessed in advance oftreatment. Nursing and medical staff in ward areas meteach morning to discuss each patient and their plan ofcare. This meant they had regular opportunities to discussconcerns, or changes to the patients’ needs and to reviewthese against the agreed plan. This could result in a referralbeing made to the specialist palliative care team or achange to discharge plans. One ward sister told us theywere able to flex staffing levels if needed to support end oflife care. Ward staff were happy with staffing levels whichthey told us had improved. Patients and relatives praisedthe level of care they had received and told us they hadregular contact with the medical team.

The same approach was not possible in the EmergencyAssessment Unit (EAU) as the number of admissions to theunit could not be controlled and patient’s needs were notpredictable. In this unit patients were often admitted fromhome via their GP and were seen by a doctor with half anhour of their admission. Specialist staff were regularlycalled to see patients on the unit staff and senior staff werealways available to support less experienced staff. Staffworked closely with the bed management team to ensurethat patients were cared for in the most appropriate placewithin the hospital.

The hospital specialist palliative care team met weekly todiscuss complex cases and participated in daily triagemeetings to review and prioritise all new referrals.

Anticipation and planningWhere a Do Not Attempt Resuscitation (DNAR) decision hadbeen made, this was clearly visible in patient’s records. Thenine forms we saw had been completed appropriately andin line with the trust’s resuscitation policy. When patientswere admitted from the community with a DNAR decisionin place this was noted. Discussions with the patient ortheir family (as appropriate) had been documented.

End of life care

Good –––


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

Good –––

Using evidence-based guidanceEnd of life care was delivered in line with relevantlegislation, current and new best practice and evidencebased guidelines and standards. National reports andguidance following review of the Liverpool Care Pathway(LCP) were available for staff to access via the trust intranet.Staff worked in accordance with guidance issued by theLeadership Alliance for the Care of Dying People, as agreedby the trust Board in 2013. The trust was one of 69 trustswho had signed up to the “Transforming End of Life Care inAcute Hospitals” initiative, which was due to beimplemented at the trust. This initiative provides acomprehensive service improvement framework andincludes use of the AMBER care bundle which assistsclinicians to identify and work with patients who arenearing the end of life.

Staff worked in line with the trust’s resuscitation policywhich referred to European Resuscitation Council and theResuscitation Council (UK) protocols.

Performance, monitoring and improvement ofoutcomesThe organisation participates in national clinical audit,reviews of services, benchmarking and clinical serviceaccreditation. Mortality rates for the trust were withinexpected limits; a breakdown of mortality rates by hospitalsite was not available. The trust took part in the NationalCare of the Dying Audit in May 2013, the results of whichwere awaited at the time of our inspection. A recent auditof GPs showed that the trust specialist palliative care teamprovided timely and useful support to GPs providingpalliative care in the community. This meant that patientswere able to be better supported to receive end of life carein their own homes.

A business case had recently been submitted with the aimof improving standards in end of life care at the JohnRadcliffe Hospital in high-pressure/turnaround areasincluding the Emergency Assessment Unit, accident andemergency and medical wards. These areas were in the top10 highest mortality spots within the hospital. We did not

see patient feedback or audits specific to end of life care inthese areas but received mixed feedback from staff. Thisindicated that patients may benefit from additional end oflife support in these areas.

Staff, equipment and facilitiesThe facilities and equipment in use reflected best practiceand had a positive impact on patient outcomes. Staff wereable to access the equipment they needed includingsyringe drivers, via the hospital equipment library.Switchover from Graseby to McKinley syringe drivers wasincluded in the educational activity action plan for 2014.This change was being implemented in line with theMedicines and Healthcare Regulatory Agency (MHRA)requirements for infusion devices. Requirements forchecking resuscitation equipment were set out in theresuscitation policy and compliance with theserequirements was audited annually.

Wherever possible patients were offered side rooms toenable privacy and dignity at the end of life. Staff in the EAUtold us they received effective support from the operationalteam, which enabled them to prioritise end of life patientsto be admitted to wards and side room facilities.

Hospital palliative care team nurses received individualtraining to ensure they were appropriately qualified andcompetent to carry out their roles safely and effectively inline with best practice. End of life training for non-specialiststaff was provided by members of the specialist palliativecare team. As e-learning was not available, capacity fortraining staff in end of life care was limited. Two study daysper year were available to palliative care link-nurses whodisseminated learning to others on their ward. Additionally,100 nurses, allied care professionals and 45 clinical supportworkers and housekeepers from across the trust’s hospitalshad attended study days in palliative care in 2013. Thesesessions were fully subscribed. The specialist team alsoprovided training to junior doctors and medical students aspart of their education and induction programmes andsome ward based sessions.

Two link nurses for palliative care had been identified oneach ward we visited. We found that one of the three linknurses we spoke with had not completed any study days inpalliative care but they were aware of the palliative carelink group page on the intranet. Responsibility foridentifying link nurses and making sure they attendedstudy days lay with individual wards. Uptake of the role wasnot monitored centrally, so it was not clear if all wards had

End of life care

Good –––


identified link nurses in place. These study days were wellattended but staff were sometimes pulled off courses atshort notice to meet staffing needs in their ward areas. Thiswas significant as it meant equipment updates or newinitiatives may not be communicated to staff on all wards.A ward sister told us that it could be difficult for nurses tofind time to carry out link roles.

Multidisciplinary working and supportA multidisciplinary collaborative approach to care andtreatment involved a range of providers across health andsocial care systems. An integrated advance care planningdocument produced jointly with the Oxford Health NHSFoundation Trust had been in use at the hospital since2012. This was completed by the patient either with theirGP or in hospital and was shared with ambulance servicesand uploaded to the trust’s patient record systems. Thespecialist palliative care team ran a community basedservice, with nurses linked to GP practices acrossOxfordshire. Telephone triage and day care services wereprovided from the Churchill hospital site.

Treatment plans for patients were determined withmultidisciplinary involvement as well as the involvement ofpatients and those close to them (this includes proactivedischarge planning, referral to other organisations andtransitional arrangements). Multidisciplinary and hospitalteam meetings were held regularly to discuss treatmentplans, including admission or referral to hospice orcommunity based services. An end of life dischargeplanning checklist was used by staff to ensure that the rightservices and equipment were in place for patients ondischarge. The fast track continuing healthcare pathwaywas used to support patients whose condition wasdeteriorating rapidly and wished to go home to die. Thehospital’s bereavement and chaplaincy services workedwith community-based organisations to ensure thatpatients’ religious needs were met and families weresupported to make appropriate arrangements after theirrelative’s death.

Are end of life care services caring?

Good –––

Compassion, dignity and empathyStaff demonstrated commitment to providing good end oflife care which met individual patient’s needs. They told us

how they ‘pulled out all the stops’ to make sure patientsgot home to die when this was what the patient wanted.Staff on the Emergency Assessment Unit (EAU) expressedregret and frustration regarding patients admitted to theunit from nursing homes for end of life care as the EAUenvironment was often busy, noisy and had limited privatespaces. They worked with operational staff to make surethat wherever possible patients were admitted to a sideroom or ward where they could have privacy and dignity atthe end of life. Despite the fact that this was not alwayspossible, staff felt they made a positive difference forpatients and their relatives.

Patients and their relatives on the medical wards told usthat staff were very caring, kind, considerate and sensitiveto their needs. They had been given options to keep themcomfortable, they felt safe, they got what they needed, andnothing was too much trouble. Staff treated them as awhole person.

Involvement in care and decision makingPatients were able to refer themselves to the specialistpalliative care team and could “just ask” when they wantedto speak with a member of the hospital team. They hadregular contact with the doctors responsible for their careand were asked how they felt and what they thought.Patients were involved in discussions about their dischargeand treatment plans and were informed about the progressof their illness. When they declined specific treatmentoptions this was respected. Discussions with patients and/or their relatives around Do Not Attempt Resuscitation(DNAR) decisions were recorded in patient’s records.

Written information for patients described the services andsupport available and gave contact information for theorganisations concerned.

Trust and communicationStaff developed positive relationships with patients usingthe service and those close to them. Some patients got toknow staff over the course of their illness, through repeatedadmissions or use of hospice services. When thishappened, patients regularly chose the ward or hospicethey attended as the place they wanted to die. Weobserved that staff communicated with patients in arespectful way. Patients and their relatives saidcommunication was excellent and staff made sure theyunderstood the explanations given. Staff had time forpatients and were happy to repeat any information andanswer questions.

End of life care

Good –––


Staff respected the patient’s right to confidentiality andused quiet rooms where possible when discussing optionswith patients. When the patient did not want theirdiagnosis shared with their relatives this was respected.

Emotional supportPatients were supported by trained staff to copeemotionally with their treatment and care during their stayin hospital. The Trust had recently established apsychological medicine service which was integrated withthe hospital palliative care team. In addition to assessingand treating patients this service supported hospital staffto enhance the psychological care they gave to patients.Hospital palliative care nurses completed a course inadvanced communication skills.

Hospital chaplains were available to provide pastoralsupport to patients and their families at all times.Chaplains ensured that patients’ religious needs were metby arranging for a representative from their faith /religion tovisit them if this was wanted. When issues were raised tothem they signposted patients to the Patient Advice andLiaison Service (PALS) and when agreed reported issues in‘real time’ to relevant staff members. This meant that anyissues could be addressed directly in order to improve theoutcome and experience for the patient.

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

Good –––

Meeting people’s needsThe trust actively engaged and worked with localcommissioners of services, the local authority, otherproviders, GPs, patients and those close to them toco-ordinate and integrate pathways of care that met thehealth needs of the local population. The specialistpalliative care team were part of the Oxfordshire End of LifeCare Reference Group which worked strategically to ensurethat the services commissioned in Oxfordshire met localneed. The team had recently set out a commissioningproposal to improve palliative care services in the JohnRadcliffe hospital on weekends. If approved this wouldmean patients would have access to a member of the

specialist team seven days a week and specialist nurseswould be on site to assist and support staff every day. Thehospital team aimed to see all patients as frequently as thepatient needed them.

Staff in the Emergency Assessment Unit (EAU) also told usthat side (single) rooms not always available to patients forend of life care. This was due to having four side rooms inthe unit and needing to manage competing priorities suchas infection control risks. Due to the nature of EAU, thismeant that end of life care was sometimes provided in abusy and noisy environment where conversations andactions could be overheard. Senior staff told us that EAUwas due to be reconfigured to add more side rooms. TheTrust reported on a survey of how side rooms were used intheir 2012/13 Quality Account. This demonstrated that siderooms were offered to patients for end of life care wherethey were available. New builds included more side rooms.Facilities for relatives had been reviewed and prioritiesidentified.

Vulnerable patients and capacityThe provider had a process in place to decide if a patienthas capacity to consent and, where a patient did lackcapacity, made sure that their best interests were assessedand recorded. The provider ensured that the needs andwishes of people with a learning disability or of people wholack capacity are assessed and monitored appropriately.Staff demonstrated understanding of the requirements ofthe Mental Capacity Act (2005) and told us how therequirements were met in their ward areas. Advance CarePlanning discussions were captured on an integrateddocument which included reference to Advance Decision toRefuse Treatment/Living Will documents and Do NotAttempt Resuscitation (DNAR) decisions. This proactiveapproach meant that people with life-limiting conditionscould record their wishes so they could be taken intoaccount if they lost capacity to make decisions when thetime came. We saw evidence that capacity assessment wasundertaken appropriately and any best interest decisionswere recorded. Guidance and policy documents containedappropriate and timely reminders to assist staff in ensuringrequirements were met.

Access to servicesThe provider was proactive in taking action to removebarriers that people face in accessing or using the servicee.g. making reasonable adjustments for disabled peopleand homeless people. Staff worked with County Council

End of life care

Good –––


social workers to meet the needs of homeless people. Thisincluded referral to Michael Sobell House hospice for endof life care. Translators were available on the same day. Inan emergency or with short notice a telephone-basedservice was available.

The chaplaincy team were mostly Christian with oneMuslim part-time chaplain in the team of six who coveredthe Trust’s four hospital sites. The team made sure patientsreceived the support they needed by facilitating visits froman appropriate member of the patient’s religiouscommunity, with whom the hospital had voluntarycontracts. Chaplaincy services aimed to see all patientsreferred to them within half an hour and this was achievedin 90% of cases including times of high demand. Nurseshad close working relationships with chaplaincy serviceswho they described as “very responsive”. The hospital hada small multi-faith prayer room which was accessed by anaverage of 250 people per day. Funding was in place toimprove this room to enable it to be used more effectivelyby different faith communities.

Leaving hospitalStaff made sure that arrangements to discharge or transfera patient met their needs and happened at the right time intheir care or treatment programme. Options for care werediscussed with patients and their views were sought.Patients told us they felt involved in discharge planning.They told us about decisions they had made, or optionsavailable and when these would be discussed. Whenpatients expressed a wish to return home for end of lifecare they were referred to an occupational therapist earlyin the process, to assess their need for a care packageincluding equipment or home adaptations.

Staff found that getting patients home for end of life carequickly could be a challenge but they were highlycommitted to making this happen and to ensuring patient’swishes were met. The average time to “fast track” a patientwas 48 hours. Nurses on one ward described how thewhole team worked together to get patients home, theyoften achieved this within 24 hours. Staff understood whatservices were available in the community and knew whothey needed to involve. Staff also used the trust’sSupported Hospital Discharge Service (SHDS) to facilitatetimely discharge. This service provided home care forpatients which meant that the hospital was less reliant on

other agencies to put services in place, so patients could bedischarged more quickly. This initiative meant patientswere not delayed in hospital unnecessarily when they wereready to return home.

Learning from experiences, concerns andcomplaintsThe provider ensured that both its complaints procedureand ways to give feedback were easy to use. Servicesencouraged patients, their relatives and those close tothem to provide feedback about their care. Patients told usthey would speak to a nurse or staff member in charge ifthey had a complaint or concern to raise. Three complaintsregarding end of life care at the John Radcliffe hospital hadbeen logged in 2013 and one in February 2014.Investigations had been completed for two of these andthese complaints had been partially upheld. One of thesecases had been referred to the clinical governance team tomake sure that a similar incident was avoided in the future.

The chaplaincy service signposted patients to the PatientAdvice and Liaison Service (PALS) and reported anycomplaints or concerns to the medical or nursing teamconcerned to address in real time. Feedback was recordedin the chaplaincy service database, but this was not sharedmore widely to contribute to service improvement. Thismeant opportunities for resolving common, potentiallymore minor issues which negatively impacted on patientexperience may be lost. In one of the four complaintsreceived the complainant had not received a responsefrom PALS.

The trust was piloting a real-time patient feedback systemfor end of life care at the Churchill Hospital and MichaelSobell House. The aim was to introduce a real-timefeedback system across the trust’s hospital sites.

Are end of life care services well-led?

Good –––

Vision, strategy and risksImproving end of life care was a quality priority for the trustin the 2012 to 2013 financial year and progress wasreported in the trust’s Quality Account for that year. Fourkey areas for improvement had been identified and theseremained as key objectives for end of life care. A local toolhad been developed and piloted to assist clinical staff to

End of life care

Good –––


identify when patients were reaching the end of life. Thetrust decided not to pursue use of the local tool but signedup to the “Transforming End of Life Care in Acute Hospitals”initiative, which was due to be implemented. This initiativeprovides a comprehensive service improvement frameworkand includes use of the AMBER care bundle which assistsclinicians to identify and work with patients who arenearing the end of life. A clear position had been agreed onuse of Liverpool Care Pathway (LCP) and a dischargechecklist had been developed and implemented tofacilitate patient discharge home for end of life care. Norisks had been identified in relation to achieving theseobjectives.

Governance arrangementsThe trust committed to developing and implementing anannual audit programme in 2013 to 2014. The trust tookpart in the National Care of the Dying Audit in May 2013, theresults of which were awaited at the time of our inspection.This was a robust audit involving over 200 hours of work tocomplete and would be expected to identify areas of goodpractice and areas where improvement was needed tomeet national standards. A business case had beensubmitted by the specialist palliative care team withsupport of a board member, which included anadministrative post to audit of end of life care. A local auditprogramme would provide timely feedback and assurancethat local strategic objectives had been met. This wasindicated as some risks identified on the trust risk registersmay impact on achieving trust objectives. In particular,increased use of locum and agency staff to address achieveadequate medical and nursing cover.

Responsibilities for governance of end of life care were notclearly defined and understood by staff. Members of thespecialist palliative care team did not have a clearreporting pathway through which issues or concerns aboutend of life care could be escalated to the trust board. Theyalso did not know which board director has strategicresponsibility for end of life services. The specialist teamwas located in the surgery and oncology division andworked in an advisory capacity to support other clinicians.This meant they did not have oversight of complaints andincidents relating to end of life care across the hospital andthey had limited influence to drive improvement throughall hospital divisions.

Leadership and cultureStaff demonstrated the values underpinning the trust’s“Delivering Compassionate Excellence” vision. Members ofthe specialist palliative care team and palliative care linknurses were especially well informed, highly motivated,keen to learn and contribute to improving end of life care.They were committed and passionate about getting end oflife care right for patients. They were motivated to affectimprovement and share their knowledge and expertisewith their colleagues.

The specialist palliative care team provided leadership inend of life care. They worked strategically as part ofOxfordshire End of Life Care Reference Group, includingsubmitting commissioning proposals to ensure that localneeds were met. A member of the team was chair of thenational Leadership Alliance for the Care of Dying Peopleand National Clinical Director for End of Life Care. Thismeant initiatives and proposals made by the team wereconsistent with national priorities and quality standards.The team had submitted a business case to fundappointment of a second specialist palliative careconsultant and two additional specialist nurses at the JohnRadcliffe hospital. The aim of this was to improve end of lifecare from the time of admission, particularly in short stay,high-pressure areas where there were many competingpriorities.

Patient experiences, staff involvement andengagementThe trust was piloting a real time patient feedback systemfor end of life care at the Churchill Hospital and MichaelSobell House hospice. If successful the system would berolled-out to the John Radcliffe hospital. The Friends andFamily Test was used to collect comments from in-patientsat the hospital and Patient Stories were used at the QualityBoard meetings to address issues and share good practice.The trust held public meetings to hear people’s views inMarch and October 2013. These trust-wide initiativescovered all areas of patient care and were not specific toend of life care.

Staff who did not have an extended or specialist role inpalliative care felt supported by their senior colleagues andthrough access to advice from the specialist palliative careteam.

End of life care

Good –––


Learning, improvement, innovation andsustainabilitySenior staff demonstrated a positive attitude towardcomplaints and audit and described how they worked tosupport junior colleagues. This included coming in early orstaying late on allocated administration days, to ensurethey were available to staff on night shifts. They told us thatissues raised by staff were taken forward. Senior nursessupported junior doctors to obtain appropriate guidancewhen prescribing pain relief as due to their inexperience inpalliative care medicine they may prescribe less than wasneeded. Senior nurses felt supported by their line

managers and told us their concerns would be listened to.Staff in the Emergency Assessment Unit (EAU) told us thatmembers of the board regularly visited the unit and theywould be happy to raise any concerns directly to them.

The hospital specialist palliative care team were supportedby the wider palliative care team. The team’s operatingpolicy included training and supervisory arrangements andexpectations for team members. The team were part of theThames Valley Strategic Cancer Network and contributedto training in the network, at Michael Sobell House andacross the Trust.

End of life care

Good –––


Safe Good –––

Effective Not sufficient evidence to rate




Information about the serviceThe John Radcliffe Hospital provided 364,572 outpatientconsultations in 2012/13, which accounted for 42% of thetotal trust-wide activity. The hospital provides outpatientservices for general surgery, vascular surgery, cardiology,gastroenterology, trauma, neurosciences and specialistsurgery. This included including Ear, Nose and Throat(ENT), ophthalmology, plastics, oral and maxillo-facialsurgery. Outpatients for maternity and children’s serviceswere inspected as part of these services and are reportedon under the relevant sections of our report.

Patients and commissioners raised concerns about delaysin getting appointments and the potential poor impact thishad on people’s health and wellbeing. We were told thatsome clinics were overbooked, which meant some patientsexperienced long waiting times in clinics, particularly inophthalmology. Healthwatch told us that long clinic waitsimpacted on volunteer drivers, as updates about waitingtimes in clinics were not always provided. In our survey inFebruary 2014, people expressed frustration with theappointment administration system and told us thatreception staff could be cold and unhelpful, offering noexplanation or apology for delays. The Trust told us thatoutpatient administration was an area of significantchallenge for them in ensuring quality of care and patientsafety. This included access to appointments via theChoose and Book system and some people waiting longerfor an appointment than the national standard.

We visited general surgery, vascular surgery, cardiology,gastrology, ENT, ophthalmology, oral and maxillo-facialsurgery clinics. We spoke with 18 patients and 40 membersof staff and observed staff interactions with patients.

Summary of findingsPatients received safe care because risks to patientswere understood and were being managed. Hospitalpolicies were based on national standards andevidence-based guidelines and adherence with thesewas monitored. An uncommissioned 10% rise indemand for outpatient appointments over the past yearmeant the Trust struggled to meet national standardsfor referral to treatment time (RTT) for patients. TheTrust agreed to fail RTT targets for January, February,and March 2014 with the NHS Trust DevelopmentAuthority, who provide oversight and governance for allNHS Trusts, to enable patients who had been waitinglongest to be prioritised. This meant that patient safetywas prioritised over meeting targets.

Patients were unable to book into appointments usingthe Choose and Book system on 50% of attempts as thiscould not be done online and there were not enoughadministrative staff available to answer calls and makebookings. This resulted in poor experiences for somepatients when trying to book appointments, to makequeries or change appointments. The way clinics wereset up in booking systems did not make the best use ofclinic facilities available, which meant that patientssometimes faced unnecessarily long waits to be seen inclinic. In order to address capacity issues, a trust-wideproject was in progress to increase the number ofappointments available and to ensure that clinicfacilities were used more efficiently. This project was onschedule and was due to be rolled-out to clinics in May/June 2014.

Clinics and waiting areas were clean and wellmaintained but space was limited, which meant waiting

Outpatients

Good –––


areas were often overcrowded. Initiatives were in placeto improve the experience for patients and keep theminformed of waiting times but these were not usedconsistently in all clinics.

Despite administrative challenges, patients were highlycomplimentary about the clinical care they received.Staff were appropriately trained, motivated, and workedwell together to ensure that outcomes for patients weregood.

Are outpatients services safe?

Good –––

Safety and performanceThere were effective arrangements in place for reportingpatient/staff safety incidents and allegations of abuse,which are in line with national guidance. There are clearaccountabilities for incident reporting and staff at all levelscan describe their role in the reporting process, areencouraged to report, are treated fairly when they do, andget feedback on what has happened as a result. Atrust-wide incident reporting system (Datix) in place, thiswas accessible to all staff and a password was not required,which meant incidents could be reported by any memberof staff. We saw that outpatient clinics had a positivereporting culture, which meant staff were more likely toover-report than under-report concerns. Incidents wereescalated to appropriate staff for investigation and agreedtime limits for responses were adhered to.

The organisation understood internal/externalperformance indicators and reviewed performancealongside other information, for example, patient feedbackand staffing levels. Concerns had been raised aboutpatients having timely access to the Age related MacularDegeneration (AMD) service after sight deterioration wasreported for three patients where access to care wasdelayed. This occurred following a change to NationalInstitute for Health and Care Excellence (NICE) guidelines,which resulted in increased unanticipated demand onophthalmology services. This was recorded on the Trustrisk register which demonstrated the action had beentaken to mitigate this risk.

Referral to Treatment (RTT) targets were not being met bythe trust, this included delays in accessing specialistsurgery, neurosciences, cardiology, endoscopy and spinalsurgery. Despite these delays no other patient safetyincidents had been reported in relation to waiting times oroutpatient clinics. Staff said that despite being very busy attimes, outpatient services were safe.

Learning and improvementIncidents were categorised according to the level of risk/concern and were escalated accordingly for action andinvestigation. Root cause analysis was undertaken inrelation to high-risk/major incidents which were captured

Outpatients

Good –––


on directorate or divisional risk registers. A review of theAMD service was carried out by the Clinical Director andadditional clinics were run to reduce the waiting list in thespecial surgery directorate by December 2013.

A trust-wide initiative to increase the number ofappointments available, and reduce waiting times was inplace. This work had been in progress since May 2013 andwas on schedule. The Trust agreed to fail RTT targets forJanuary, February and March 2014 with the NHS TrustDevelopment Authority (TDA). (The NHS Trust DevelopmentAuthority provides oversight and governance for all NHSTrusts.) This was to enable the Trust to manage the backlogof patients waiting to be seen. This approach andagreement meant that patient safety was prioritised overmeeting targets.

Systems, processes and practicesA programme of risk-based audit was carried out tomonitor adherence with the standard operatingprocedures. Action was taken as a result of findings. Auditswere carried out to check compliance with infection controlprocedures and cleanliness of the environment. Thesewere reported back to staff teams and monitored throughdivisional quality reporting. Results for ENT/ophthalmologyoutpatients for February 2014 were displayed in the waitingarea. 100% compliance had been achieved with handhygiene and the area had scored 85% for environmentalcleaning. The environment was modern and clean, handhygiene facilities were available, toilets were clean, andbins were emptied. We saw that emergency equipment wasavailable and appropriate checks had been carried out. Anequipment checking schedule was in place and detailswere held and monitored on a database.

In oral/maxillo-facial outpatients a risk assessment hadbeen completed for one treatment room where x-rayequipment required replacement and the room neededrefurbishment.

Problems had been experienced in ensuring that patientnotes were available for outpatient consultations. Thisstemmed back to implementation of the Electronic PatientRecord (EPR) system across the Trust in 2011 and wascompounded by shortage of administrative staff. Someareas experienced delays in patients’ medical notesarriving within the department, which meant they hadlimited time to locate any missing records. An unexplainederror in the EPR system resulted in some appointmentsbeing cancelled where patients were not informed, or not

informed in a timely manner. This meant their notes werenot available. This was happening in one to two cases aweek in the specialist surgery division, but was a trust-wideproblem being monitored on the Trust risk register.

When records could not be located, temporary notes werecreated by pulling off information stored in the EPR, whichmeant patient’s full medical histories were not alwaysavailable. Delays in merging temporary and original noteshad also occurred which had potential to impact onfollow-up treatment. The proportion of missing notes inclinics was variable. We saw that staff reported issues withnotes via Datix, this included when paper notes were inpoor condition. It was not clear that all staff were as vigilantin reporting as incidents were logged at the discretion ofindividual staff members. We did not see evidence ofcompleted audits to establish the extent or impact of theproblem.

Staff had access to clear information that enabled them todo their job effectively. Guidance and policies could beaccessed via the Trust intranet and all new staff wereprovided with electronic copies of policies relevant to theirjob role when they started working for the Trust. Outpatientteams met regularly which gave them opportunities toshare learning and discuss areas where improvement wasneeded. We did not see any minutes from these meetings.Some staff in ophthalmology felt that more could be doneto disseminate learning from incident and complaints. Ateam strategy meeting for ophthalmology was planned for17 March 2014 where “improving learning and embeddingchanges” was on the agenda.

Monitoring safety and responding to riskNo concerns were raised by staff about staffing levels orskill mix in outpatients. One staff member said theythought outpatients tended to be better staffed than thewards, others told us they could be stretched to their limitsand sometimes stayed late. We saw that staffing levelswere monitored and expected staffing levels versus actualstaffing levels for nurses and Clinical Support Workers(CSW) were displayed in the ENT/ophthalmology waitingarea. Minutes from the Outpatient Steering Group forJanuary 2014 showed that a staffing review was plannedfor all outpatient areas across the Trust. This was necessaryand timely in response to the trust-wide re-profiling ofoutpatient clinics, which was in progress. This means thatthe demand for services was being accessed and decisions

Outpatients

Good –––


made on the numbers of clinics needed to meet thatdemand. One consultant told us they were working 11sessions plus additional clinics to address the appointmentbacklog, which was unsustainable for them.

Staff were aware of any outstanding training requirementsthey needed to fulfil. One staff member told us they werethree months overdue for resuscitation training, as theywere needed to cover clinic on the day their training wasbooked. They said there was a lack of capacity forresuscitation training which made it difficult to book on to.Another staff member told us resuscitation training had tobe booked well in advance. While visiting maxillo-facialclinic the emergency buzzer sounded, staff respondedappropriately to this. Staff demonstrated appropriateknowledge about how to recognise and respond tosafeguarding concerns. When entered in the Datix system,safeguarding concerns were automatically escalated to theTrust safeguarding lead.

The Outpatient Steering Group was working to standardiseapproaches to outpatient service improvement across theTrust. New standards had been agreed which were to bereported on monthly. The metrics included meant thatquality issues raised through concerns, complaints andnational standards could be monitored and benchmarkedacross outpatient services.

Anticipation and planningChanges to outpatient services were being managedthrough the outpatient re-profiling project. This project wasestablished in response to the need to improve efficiencyand effectiveness, to meet national standards for waitingtimes (RTT) and Choose and Book requirements. There hadbeen an unpredicted rise in demand for outpatient servicesin the past year and the Trust was working with the ClinicalCommissioning Group (CCG) to manage this. This projectwas due to complete in May/June 2014. We wereconcerned that when the new booking system had beenrolled-out (implemented) in ENT clinics in Autumn 2013 thesystem had contributed to RTT issues and had beenwithdrawn. Changes were made to the new ENT clinicprofiles but it was not clear how the lessons learnt werebeing taken forward as the action plan was underdevelopment at the time of our inspection.

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

Not sufficient evidence to rate

Using evidence-based guidanceThe Trust Access Policy was based on NHS England’sperformance measures for hospital trusts and individualpatient rights set out in the NHS Constitution 2013. Thepolicy had been updated in August 2013.

Staff were able to access trust policies and guidance via theintranet. Staff told us trust policies they worked to werebased on Royal College, BASO (The Association for CancerSurgery) and NICE guidelines and standards. The Trust’sResuscitation Policy referred to European ResuscitationCouncil and the Resuscitation Council (UK) protocols.

Performance, monitoring and improvement ofoutcomesAdherence to NICE guidelines was monitored and wasreported in some divisional quality reports. As treatmentgenerally extended past outpatient services it was notpossible to assess outcomes for patients in outpatientclinics separately.

Clinical audit was carried out by senior nurses andindividual consultants. Team/departmental governancemeetings were held, typically every three months, todiscuss clinical governance issues and complaints.

Staff, equipment and facilitiesStaff demonstrated knowledge of evidence-basedstandards in our discussions with them. Staff hade-learning accounts from which they could book training oraccess e-learning. Nurses told us they undertookcompetency-based assessments, based on clinical policies.A clinical support worker (CSW) told us about their positiveexperience of the Trust’s CSW academy. The academyprovided induction training for them over a period of oneto two weeks when they moved into their new role inoutpatients at the John Radcliffe. This training wascompetency based and involved orientation to each areathe staff member worked in. Another staff member told usthey were able to access e-learning and work email fromhome which they found useful.

A specialist nurse practitioner told us how emergency,everyday, and specialist equipment was checked andmaintained within their clinical specialty. Patients werecomplementary about the care they received from clinicstaff, which they described as professional.

Outpatients

Good –––


Customer service training was available to receptionistsand peer review processes had been introduced for somestaff groups. Staff told us they felt well supported by seniorcolleagues.

Multidisciplinary working and supportStaff were highly complimentary about their colleagues,describing them as “fantastic” and “fabulous”. It wasevident that clinic staff worked as teams and understoodeach other’s role and contribution to the effective runningof the service. Regular team meetings were held whichwere attended by all members of the multidisciplinaryteam.

Are outpatients services caring?

Good –––

Compassion, dignity and empathyStaff in all roles put significant effort into treating patientswith dignity and patients feel well cared for as a result. Weobserved members of staff from all staff groups while theyinteracted with patients and their relatives. We saw thatreception staff sometimes worked under considerablepressure. We saw one receptionist managing misdirectedcalls, long queues and a less than polite patient alone astheir colleague had been delayed in a traffic incident.Despite this, they politely signposted the disgruntledpatient to the correct area for their appointment andsuggested that another patient who arrived early went toget refreshments and return later. The receptionists weobserved were calm and friendly throughout.

A senior staff member in another area told us thatreceptionists were a “mixed bag”; they had recentlyreported concerns about a staff member’s approach topatients to the matron for the service. Matron had alreadybeen aware of the issue and the staff member hadattended customer service training. Clinical staff werefriendly and approachable. In the consultation weobserved, the patient was welcomed by name, theconsultant introduced themselves and others in the roomand ensured the patient and their relative werecomfortably seated.

Involvement in care and decision makingPatients, relatives/carers, and advocates described feelinginvolved in planning their care and making decisions about

the choices available in their care and treatment. Patientstold us that nurses and consultants listened to them andthey had been given opportunities to ask questions duringtheir appointment. Patients in oral/maxillo-facialoutpatients told us they had agreed to future surgery. In theconsultation we observed, the patient was asked abouthow specific treatment options had previously affected anunrelated condition they had. The consultant checked thepatient’s understanding and adjusted the explanationsthey gave to make them easier for the patient to follow. Atreatment plan was agreed between the patient andconsultant.

Trust and communicationStaff developed positive relationships with patients whoused the service and those close to them. Patients valuedtheir relationships with staff and could identify the staffwho cared for them and their role and responsibility.Information about staff and their roles and a list of clinicsand what they did was visible in the ENT/ophthalmologywaiting area. Patients were positive about their interactionswith staff in all clinic areas we visited. Some patientspraised individual consultants for the way they hadmanaged their care. Another patient told us how aspecialist nurse had identified clinical changes thatrequired treatment and ongoing follow-up when theyattended eye outpatients for an unrelated emergency. Theyhad since attended the outpatient service for four yearsand described the staff member as, “Brilliant”.

Emotional supportWe did not observe any instances where emotional supportwas needed but saw that patients were treated in a caringmanner.

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


Meeting people’s needsThe provider actively engaged and worked with localcommissioners of services, the local authority, otherproviders, GPs, patients and those close to them toco-ordinate and integrate pathways of care that met thehealth needs of the local population. GPs and the hospital’s

Outpatients

Good –––


A&E department referred patients to emergency clinics inophthalmology and ENT to manage acute pain andremoval of foreign bodies. The Trust was working with theClinical Commissioning Group (CCG) to predict and plan tomeet future demand for outpatient services. An audit oftwo-week wait referrals by GPs was planned to ensure thatthe two-week wait care pathway was being usedappropriately for patients who needed to be seen urgently.Recent high discharge rates from these clinics suggestedGP training may be required.

A loop hearing system was in place in ENT and big letterswere used on signs to assist visually impaired patients inophthalmology. The facilities were clean and well set outbut clinic and waiting area space was very limited in allareas we visited. Space limitations were compounded asclinics were overbooked and patients often waited longpast their given appointment time. During our visit anannouncement was made in ophthalmology asking peoplewaiting with patients to give up their seats.

Verbal and written information that enabled patients tounderstand their care was available to patients and theirrelatives in ways that meet their communication needs,including the provision of information in differentaccessible formats and interpreting services. Leaflets wereavailable in all waiting areas, including how to raise aconcern or complaint. This leaflet included information in avariety of languages. Other leaflets included a telephonenumber and email address for assistance from aninterpreter or alternative formats. Interpreter services wereavailable and these were booked by staff when screeningpatient notes before clinic. This was usually done the daybefore clinic, but was not possible if notes were latearriving in the department or were unavailable. A three-wayinterpreter telephone service was available at any time.Healthwatch informed us that patients who were deaf hadnot always had a positive experience as interpretationservices at their appointment had been poor. Abefriending/ advisory service for blind and partially sightedpeople was also located in the ophthalmology/ENT waitingarea

Vulnerable patients and capacityNo special arrangements were in place in clinics to meetthe needs of patients with learning disability or dementia.Staff were aware that patients with these conditions mayfind the busy clinic environment difficult to cope with andtold us they would try to identify patients when they

screened their notes before clinic. If possible the patientwould be offered a quiet area to wait in. Staff were aware of“hospital passports” used by people with learning disabilityto assist them to communicate, but did not see many ofthese in brought in with patients. A nurse told us thatmeeting the needs of patients with dementia could bechallenging. Arrangements were in place to assess people’scapacity to consent to care when this was in question. Thenew core standards for outpatients included monitoringuse of a yellow sticker to identify patients with additionalneeds including those who required disabled access orhearing support.

Access to servicesThe Trust were not meeting national standards for referralto treatment (RTT) times at the time of our inspection. Anagreement was in place with the NHS Trust DevelopmentAuthority (TDA) for the Trust to fail RTT targets for January,February, and March 2014. (The NHS Trust DevelopmentAuthority provides oversight and governance for all NHSTrusts.) This had been agreed to ensure that a backlogpatients who had been waiting longer than agreedstandards would be prioritised. Additional clinics werebeing run to clear the backlog of appointments withinthese agreed timescales.

The Trust was not meeting standards for the Choose andBook service, with an average 50% failed booking ratetrust-wide. An online service was not available whichmeant that all bookings were made by telephone. Bookingpatients into an appointment using Choose and Book tookabout eight minutes, this and introduction of the TrustsElectronic Patient Record (EPR) system in 2011 had asignificant impact on administrative staff time. This impacthad not been quantified or anticipated and administrativestaff were struggling to meet demand. This resulted in poorexperiences for some patients when trying to bookappointments, to make queries or change appointments.

Not enough outpatient appointments were available tomeet demand. Clinic “templates” set out how manyappointments were available and the length ofappointment slots in each clinic. The templates in use nolonger reflected demand for appointments which had risenyear on year. With the existing templates staff were able to“force book” additional patients into clinics, causingoverbooking which contributed to long waiting times inclinics. This also meant that waiting lists were more difficultto manage and some appointments needed to be

Outpatients

Good –––


cancelled at short notice. When patients were booked intoclinics they were triaged by consultants to ensure they werebooked into the right service, this meant the appointmentmay be changed. Each time an appointment was bookedor cancelled a letter was generated and sent to the patient.The impact of these systems on patients was that they mayexperience late cancellations or multiple letters which leftthem confused. One patient showed us five letters theyreceived changing their appointments and another told usthey had travelled from Bristol to learn their appointmenthad been cancelled. Some patients had not experiencedany issues with their bookings. In response to these issuesand concerns raised by patients and the CCG a trust-wideinitiative to increase the number of appointmentsavailable, and reduce waiting times was in place. This work,to re-profile (redesign) clinic templates had been inprogress since May 2013 and was on schedule.

We found that whiteboards to inform patients of waitingtimes were used inconsistently. In the oral/maxillo facialclinic staff were waiting for the whiteboard to be put up. Incardiac and vascular clinics waiting times were not filled inwhen we arrived on one of the two days we visited, as stafftold us they had been too busy. Staff did not informpatients of delays verbally and did not apologise for thedelay when calling patients. Reception staff generally didnot know how late clinics were running and relied onnursing staff to update patient information boards. Waitingtimes were displayed in ENT and ophthalmology, staffmade verbal announcements to inform patients and a”pager call” system was in use to allow patients to leave thedepartment while waiting. Feedback from patients in theseclinics was generally complementary.

Our observations were consistent with what patients andtheir representatives told us. We were contacted by arelative who told us they had recently waited for four and ahalf hours for a cardiac appointment, where no delay wasshown on the whiteboard and staff did not communicateany delay. When they made a verbal complaint to theywere advised to complain to the doctor. The whiteboardhad not been updated when they left the clinic. Waitingtimes and parking issues were consistent themes in patientsurveys and complaints. Patients shared concerns aboutdifficultly parking, distances from the car park to clinics andpenalty fines for overstaying due to unanticipated delays inbeing seen.

Leaving hospitalWe observed that ongoing care was discussed withpatients during their consultation. The patient we observedleft clinic with a letter for another consultant they werebooked to see at the Churchill hospital the following week.In oral/maxillofacial outpatients, patients who would bereturning for surgery had some pre-operative checkscarried out at the same time as their first consultation. Thismeant they would not need to return to do this at a laterdate. They also knew when they were likely to be admittedfor surgery.

When people with dementia attended using patienttransport, staff tried to book a “wait and return” service toensure the person was not waiting unnecessarily for theirtransport to arrive.

Learning from experiences, concerns andcomplaintsThe provider was open and transparent about how dealtwith complaints and concerns. Feedback from patientsurveys was available to patients in ENT/ophthalmologywaiting areas. This included the Matron’s response toconcerns raised and the action they had taken. Staff werevery well informed about patient complaints and knewwhat the main issues were.

A senior nursing and governance lead told us how theylooked for trends from patient complaints and incidentsreported on the Datix system to improve safety and patientexperience. This informed quality priority setting for thecoming year. They identified that complaints oftenstemmed from poor communication with patients, whohad not always been informed of what to expect whenattending their appointment.

Are outpatients services well-led?

Good –––

Vision, strategy and risksTrust-wide vision and strategy was set out in the trust’sQuality Account. A clear vision for outpatient services wasset out in the trust’s Access Policy this encompassed keyelements of the NHS constitution including patent safety,choice and experience. The board was aware of potentialand actual risks to quality and safety. Risks at team,directorate and organisation level were identified and

Outpatients

Good –––


captured. There was alignment between the risks on therisk register and what staff told us they were concernedabout. The outpatients steering group met monthly toensure a consistent approach to improvement inoutpatients was achieved trust-wide.

Governance arrangementsIt was unclear how administrative shortfalls were beingaddressed to improve patients’ experience of the service.Patient feedback on NHS Choices website for February2014 showed that difficulties getting through to arrangeappointments by telephone was an ongoing source ofconcern and frustration for some patients. Similarly, whena patient had cancelled their appointment, clinic staff werenot always informed and said this made running clinicsmore difficult. Staff experienced improvements in relationto missing patient records in some clinics over the pastthree to four months.

Management of waiting lists was being monitored throughweekly meetings. Choose and Book and patient recordissues were tracked through monthly meetings and werereported in divisional Assurance, Quality and Performance(AQP) reviews.

Performance information was not always available tosenior clinical staff and some said they wanted moreinformation. Outpatient core standards and quality metricshad been agreed by the outpatients steering group. Thesewere to be reported on monthly and would enableperformance benchmarking of outpatient services acrossthe Trust. These included national standards for access tocare, availability of notes and limits on waiting times inclinics. An education pack was being drawn up to preparestaff before the quality monitoring metrics wereintroduced. An outcome measures dashboard was beingdeveloped as part of the re-profiling project. This wouldallow RTT standards and Choose and Book success rates tobe tracked.

Leadership and cultureLeadership was generally good in outpatients. Somedepartments and individuals stood out as they wereworking more openly with patients and had implementedtechnology to improve patient experience. Plans were inplace to review strategic approaches to problem solving alocal level.

There was strong team based working characterised by acooperative, inter-disciplinary, cross-boundary approach todelivering care in which decisions are made by teams.Teams had clearly defined tasks, membership, roles,objectives, and communication processes. Nursing andmedical staff reported being well supported by their seniorcolleagues. They were confident that concerns wereaddressed effectively and assistance was available to themto manage more complex clinical cases. Multidisciplinaryteam meetings had been held quarterly, these were movingto monthly in ENT and ophthalmology to ensure the teamwas prepared for roll out of the revised clinic templates.Staff felt able to approach their line manager and seniorstaff. Non-executive directors had a high profile inoutpatients and one in particular was described as veryapproachable.

Patient experiences, staff involvement andengagementStaff felt valued and supported in their work place. Despiteclinics being very busy at times and staff working at theirlimits on occasion they enjoyed their jobs and wereenthusiastic about the development opportunities open tothem. They demonstrated commitment to improving theservice and readiness to learn. Staff spoke highly of eachother and the way the teams worked together. They valuedthe contributions their team members made.

Several ways of obtaining patient feedback had been used.These included patient surveys and complaint monitoring.Special kiosks had been ordered to capture patientfeedback electronically in real time. These were in use inclinics in other hospitals in the Trust. An open day hadbeen held in an outpatient unit over a weekend, this gavepatients an opportunity to ask questions and share theirviews. Patient pathways through ophthalmology clinic hadbeen plotted, to show times required for different steps inthe process. This had been shared with the patientinvolvement group through a focus group.

Learning, Improvement, innovation andsustainabilityImprovement initiatives and good practice were sharedthrough the outpatient steering group. This group enabledmanagers and nursing staff to share their experience andlearning and to support each other to implement changes.

Outpatients

Good –––


Action we have told the provider to takeThe table below shows the essential standards of quality and safety that were not being met. The provider must send CQCa report that says what action they are going to take to meet these essential standards.

Regulated activityTreatment of disease, disorder or injury The provider had failed at times to plan and deliver care

to patients needing emergency care, surgical care andoutpatient care to meet their needs and ensure theirwelfare and safety.

This is a breach of Regulation 9(1)(b)(i) and (ii) of theHealth and Social Care Act 2008 (Regulated Activities)Regulations 2010.

The accident and emergency department were regularlymissing waiting-time targets due to the lack of availablebeds to discharge people effectively.

The outpatient department was failing to provide aneffective booking service, failing to meet nationalstandards for timely referral to treatment and failing toprovide suitable information.

In some surgical specialties waiting times for surgerywere too long and operations were cancelled too often.

There was not suitable attention paid to theidentification, assessment and planning of care needsfor vulnerable people, particularly those with dementiain surgery and A&E.

Regulated activitySurgical procedures The provider had failed at times to plan and deliver care

to patients needing emergency care, surgical care andoutpatient care to meet their needs and ensure theirwelfare and safety.

This is a breach of Regulation 9(1)(b)(i) and (ii) of theHealth and Social Care Act 2008 (Regulated Activities)Regulations 2010.

The accident and emergency department were regularlymissing waiting-time targets due to the lack of availablebeds to discharge people effectively.

Regulation

Regulation

This section is primarily information for the provider

Compliance actions


The outpatient department was failing to provide aneffective booking service, failing to meet nationalstandards for timely referral to treatment and failing toprovide suitable information.

In some surgical specialties waiting times for surgerywere too long and operations were cancelled too often.

There was not suitable attention paid to theidentification, assessment and planning of care needsfor vulnerable people, particularly those with dementiain surgery and A&E.

Regulated activityTreatment of disease, disorder or injury The provider had failed to consistently safeguard the

health, safety and welfare of patients because they didnot ensure that that at all times there were sufficientnumbers of suitably qualified, skilled and experiencedstaff employed

This is a breach of Regulation 22 of the Health and SocialCare Act 2008 (Regulated Activities) Regulations 2010.

There were not sufficient numbers of suitably qualified,skilled and experienced staff employed in the maternitydepartment and on surgical wards and in operatingtheatres.

Regulated activitySurgical procedures The provider had failed to consistently safeguard the




Regulation

Regulation


Compliance actions


Regulated activityFamily planning The provider had failed to consistently safeguard the




Regulated activityMaternity and midwifery services The provider had failed to consistently safeguard the




Regulated activityTermination of pregnancies The provider had failed to consistently safeguard the



Regulation

Regulation

Regulation


Compliance actions



Regulated activityTreatment of disease, disorder or injury The provider had failed at times to deliver care to

patients that ensured their privacy, dignity and humanrights were respected.

This is a breach of Regulation 17(1)(a) and (2)(a) of theHealth and Social Care Act 2008 (Regulated Activities)Regulations 2010.

The use of the accident and emergency triage room, theatrium area, and layout of the reception did not givepatients privacy and dignity.

Regulated activityTreatment of disease, disorder or injury The provider did not have suitable arrangements in

place in order to ensure that all staff were appropriatelysupported in relation to their responsibilities to enablethem to deliver care and treatment to service users to anappropriate standard through receiving appropriatetraining, professional development and supervision.

This is a breach of Regulation 23(1)(a) the Health andSocial Care Act 2008 (Regulated Activities) Regulations2010.

Some of the new nursing staff coming to work at thehospital did not have sufficient induction into the A&Edepartment. Newly qualified midwives did not alwaysreceive adequate preceptorship. Not all nurses qualifiedoverseas working in A&E and newly qualified midwiveswere appropriately supervised to ensure they werecompetent and trained to deliver all care and treatmentprocedures to the appropriate standard.

Regulated activity

Regulation

Regulation

Regulation


Compliance actions


Maternity and midwifery services The provider did not have suitable arrangements inplace in order to ensure that all staff were appropriatelysupported in relation to their responsibilities to enablethem to deliver care and treatment to service users to anappropriate standard through receiving appropriatetraining, professional development and supervision.

This is a breach of Regulation 23(1)(a) the Health andSocial Care Act 2008 (Regulated Activities) Regulations2010.

Some of the new nursing staff coming to work at thehospital did not have sufficient induction into the A&Edepartment. Newly qualified midwives did not alwaysreceive adequate preceptorship. Not all nurses qualifiedoverseas working in A&E and newly qualified midwiveswere appropriately supervised to ensure they werecompetent and trained to deliver all care and treatmentprocedures to the appropriate standard.


Compliance actions


cqc john radcliffe report

Documents