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John Radcliffe Hospital Requires improvement

We are carrying out checks at John Radcliffe Hospital using our new way of inspecting services. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 14 May 2014

The John Radcliffe Hospital, Oxford is the largest hospital in the Oxford University Hospitals NHS Trust, with 832 beds, and serves a population of around 655,000 people. It provides acute medical and surgical services, trauma, and intensive care and offers specialist and general clinical services to the people of Oxfordshire. The John Radcliffe Hospital site includes the Children's Hospital, Oxford Eye Hospital, Oxford Heart Centre, Women's Centre, Neurosciences Centre, Medical Emergency Unit, Surgical Emergency Unit, and West Wing. It is Oxfordshire's main accident and emergency (A&E) site. The trust provides 90 specialist services and is the lead hospital in regional networks for trauma; vascular surgery; neonatal intensive care; primary coronary intervention and stroke. It also works in collaborative networks with Stoke Mandeville, for specialist burns services and with Southampton for paediatric specialist services in cardiac care, neurosurgery, and critical care retrieval.

The hospital is registered to provide services under the regulated activities:

  • Assessment or medical treatment for persons detained under 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 Radcliffe hospital were delivered to a good standard, but overall the hospital required improvement. The hospital was failing to plan and deliver care to patients needing A&E, surgical and outpatient care and to meet their needs and ensure their welfare and safety. Patient records were not being completed in some areas of the hospital.

Shortages of staff within the maternity department, on surgical wards and in operating theatres meant that staff were not able to provide the best care at all times. There were not sufficient numbers of qualified, skilled, or experienced staff to meet patients’ needs at all times. The trust delivers a number of induction programmes for new staff. However, some staff we spoke with did not always feel appropriately inducted or supported.

Staffing

Although in many areas of the trust there were sufficient staff to meet people’s needs this was not the case in the maternity department, surgical wards and operating theatres.

The trust told us that they had difficulties recruiting staff because of the high cost of living within Oxford and because of the difficulties and cost of parking on the hospital site. The trust told us there had been a recruitment drive and a recent cohort of registered nurses from Spain had recently started work. Recruitment was ongoing and further recruitment drives in Scotland and Wales were planned.

There were nursing and healthcare assistant staff shortages reported on surgical wards and in theatres. In December 2013 the vacancy rate for nursing staff was 16.4% in the neurosciences, orthopaedics, and trauma and specialist surgery division. We saw evidence of patients who were fit to be transferred from the intensive care unit onto a surgery ward, but because of staff shortages, there were no beds available in the surgical wards. This put pressure on staff to discharge patients to create capacity.

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

We were told that operating lists were cancelled about once a week due to staff shortage. Theatre staff told us that sometimes theatres had only two theatre staff supporting the surgeon and anaesthetist. The Association for Perioperative Practice (AfPP) recommends that there should be three staff (three nurses or two nurses and one operating department practitioners (ODPs). Staff in the main theatres told us that they regularly had only two staff. 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 the medical staffing levels felt unsafe. Out of hours there was one junior doctor (Senior House Officer) looking after 74 inpatients, while a registrar provided emergency cover. There was no phlebotomy service, which added further to their workload. We saw this in practice during our unannounced visit.

In maternity services the delivery suite had been without a manager for 18 months. Elements of the role were being covered by three band 7 midwives over three days a week. The trust had attempted to recruit to this role. Although the delivery suite provided women in labour with one to one care, staffing levels were not always sufficient to ensure women received the care and support they needed. Where recruitment to new posts occurred this was of newly qualified midwives who needed support from the experienced midwives within the department. This added further pressure to those staff. In addition, newly qualified midwives reported not receiving adequate preceptorship. The number of supervisors of midwives was below that recommended in national guidance from the Nursing and Midwifery Council. There was not sufficient consultant presence within the delivery suite to meet national standards, although midwifery staff reported that consultants were supportive.

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

Cleanliness and infection control

Within the hospital there were suitable infection control procedures and practices. Hand-washing facilities were clearly indicated in departments and hand sanitising gel was placed appropriately. Staff said they had enough personal protective equipment including gloves and aprons. In most areas nursing staff were wearing standard uniforms and all staff we saw were adhering to infection control protocols (such as being “bare below the elbow”, without nail varnish, and wearing minimal jewellery).

Infection control procedures, for example, hand hygiene and cleaning audits, were undertaken monthly and the results displayed in specific areas of hospital. The hospital was clean. We saw staff washing their hands and wearing aprons and gloves. On the adult intensive care unit hand hygiene was assessed at only 87% completed and cleaning at only 83%. The matron advised that ongoing works takes place to review all areas audited. We observed good hand hygiene taking place in all areas. However, we noted that staff in intensive care did not adhere strictly to the uniform policy with hair touching collars and earrings which was not in line with the trust policy.

The level of hospital acquired infections was monitored within the hospital. Reported Clostridium Difficile and methicillin resistant Staphylococcus Aureus (MRSA) bacteraemia were within expected limits. Each reported case underwent an in-depth review, and were discussed at the infection control committee. We saw good practice in the children’s A&E department where a child with chicken pox was cared for in a cubicle.

Inspection areas

Safe

Requires improvement

Updated 14 May 2014

We found the services at the hospital were safe however some improvements were required. Staffing in maternity, operating theatres and on surgical wards was 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 of living in Oxford. Some patient records did not provide sufficient information to staff about how to support patients. This could mean that patients’ care was not as effective as it could be.

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

Monitoring of safety occurred throughout the hospital. This included monitoring of pressure ulcers, falls, venous thromboembolism and patients with catheter related urinary tract infections and action to minimise the occurrence of these.

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

Effective

Good

Updated 14 May 2014

Outcomes for patients were good and the hospital performed well when compared with other similar organisations. Care and treatment was delivered in line with most national guidance and best practice. Adherence to guidance was monitored in divisional areas and reported through the governance system within the hospital. Staff worked in multidisciplinary teams with care focused around the patient. Although adherence mandatory training was good within the hospital, in some areas staff had not received specific training to support people with dementia or a learning disability.

Caring

Good

Updated 14 May 2014

In most areas of the hospital we observed staff providing care with compassion and treating patients with dignity and respect. Privacy was respected and curtains were pulled around patients’ beds while care was being provided. Most patients spoke positively about the kindness and care provided by staff. However, at busy times within the A&E department some patients were not made to feel safe or comfortable. We saw patients being placed in an atrium or corridor at the front of the A&E entrance before moving to a ward or going home. Although patients were unhappy about waiting in this area, they said the nursing staff had been fantastic.

There were privacy issues within the A&E department. People could be heard providing personal information at the reception desk and most of those we spoke with said they felt they had to provide information to the reception staff about why they were visiting the department.

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

Responsive

Requires improvement

Updated 14 May 2014

Patients experienced difficulties in accessing services to meet their needs in a timely manner within A&E, surgery and outpatients because national targets for waiting times were not met. Patients were not provided with suitable information about the waiting times in A&E and outpatient departments.

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

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

There was a lack of capacity within operating theatres in the hospital. The hospital was working towards achieving national targets in relation to waiting times for operations, cancelled operations and delayed discharges and scored similarly to expected when compared with other trusts. However, staff said that operations were regularly cancelled due to lack of theatre capacity, shortage of staff or inefficient planning. They said there were issues around the management of the waiting time target which led to theatre lists being overbooked. There were dedicated emergency theatre sessions and an emergency bookable theatre list process which was monitored through monthly reporting to the trust board. However, we were told that if emergency cases arose, planned surgery was cancelled.

Similarly in outpatients, “referral to treatment” targets were not being met, with patients waiting longer than agreed standards for outpatient appointments. There were not enough appointments to meet demand and clinic “templates” (which set out the number of appointments in each clinic) did not reflect that demand following year on year increases. Clinics were overbooked causing long waiting times. The hospital was also not meeting standards within the Choose and Book service. The impact on these systems was that patients may experience late cancellations of appointments or multiple letters which proved confusing. Work to reprofile (redesign) clinic templates had been in progress since May 2013 and was on schedule.

Well-led

Good

Updated 14 May 2014

Overall the services within the hospital were well led. There was a clear trust vision and a set of values, which were patient focused. Staff in some areas did not know what the vision and values were but portrayed similar values and passion and motivation to provide excellent patient care.

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

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

Checks on specific services

Maternity and gynaecology

Good

Updated 14 May 2014

Women received care and treatment from caring, compassionate, and skilled staff. We received positive comments from women and their families about the care and support they received.

The delivery suite had been without a manager for the 18 months prior to our inspection due difficulties in recruitment. Elements of this role were being covered by three band 7 midwives, but this did not provided consistency in the management of the delivery suite. Although the delivery suite provided women in labour with one-to-one care, staffing levels were not always sufficient to ensure women received the care and support they needed. Recruitment that had occurred was of newly qualified midwives who needed support from the experienced midwives within the department. This added further pressure to those staff. In addition newly qualified midwives reported not receiving adequate preceptorship. There were insufficient supervisors of midwives in post to meet guidance from the Nursing and Midwifery Council. There was insufficient consultant presence within the delivery suite to meet national standards, although midwifery staff reported that consultants were supportive.

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

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

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

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

The maternity unit was clean and staff followed the internal procedures for hand washing. Hand gels were available at different points and visitors were encouraged to use them. Staff had completed training in infection control to ensure women and babies were protected 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 support from clinicians at all levels which, in turn, had positive impacts on patients care.

There were clinical governance strategies and regular meetings which looked at 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 well led. Staff reported that they felt supported by their immediate line managers and there was suitable governance processes in place.

Medical care (including older people’s care)

Good

Updated 14 May 2014

Staff provided a safe service to patients receiving medical care. Systems were in place to report, respond, and monitor safety issues across all levels of medical care. Safe staffing levels had recently been reviewed and several medical wards had increased their staffing to support the needs of frail, elderly patients. Recruitment of staff to medical wards had been successful and the hospital continued to recruit into vacancies.

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

Some patients had multiple health, social and/or psychological needs, which required the input of several specialist teams. The multidisciplinary teams in the division were well integrated and had a strong collaborative approach to care. Care and treatment that was agreed and delivered was not always recorded. A written record was not always available to all parties to ensure continuity 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 and staff knew how to protect the rights of patients who lacked capacity to make decisions about their treatment. Efforts were made to ensure patients stayed in contact with friends and relatives. The hospital had taken account of relatives concerns and action plans were in place to improve communication between staff and relatives.

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

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

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

Urgent and emergency services (A&E)

Requires improvement

Updated 9 May 2017

  

Overall we rated this service as requires improvement because:

During the time of the inspection we observed crowding in the emergency department (ED), the majority of patients were not assessed within 15 minutes of arrival in the department, this included patients who arrived by ambulance. Some patients waited more than one hour before an initial assessment. This meant there was a delay to undertaking the sepsis screen.

The department performed significantly worse than the England average for the four hour A&E waiting time target.

At the time of the inspection the trust had not completed their formal review of acuity and establishment in the ED.  Over a four month period, July to October 2016 over half the shifts were staffed at minimum nurse staffing levels. Over a four month period, July to October 2016 over half the shifts were staffed at minimum nurse staffing levels. There were five ED consultant vacancies. Consultant cover was provided by ED consultant for 16 hours daily and on call. A trauma and orthopaedic consultant provided cover for major trauma calls.

The space and layout of the department significantly affected the efficiency in the department. The resuscitation area contained four bays and we observed it was often used to accommodate more than four patients. In cases when capacity did not meet demand a screened corridor, was used to accommodate up to six patients on trolleys

The department was not able to provide consistently safe arrangements for the care of patients with mental health conditions or at risk of absconding.

Resuscitation training and safeguarding training for medical and nursing staff was below the 90% trust target. The trust’s statutory and mandatory training policy did not require administrative and clerical staff to undergo safeguarding adults training. Low numbers of medical staff were compliant with Mental Health Act and Deprivation of Liberty Safeguards training.

Appraisal rates for nursing staff were significantly below the trust target of 90% at 61% in ED and 46% in EAU.

Staff did not consistently record the time of review in the patients’ records. All patients' pain was not managed in a timely manner.

Multidisciplinary working was variable. For example, junior medical ED staff found that the staff in the surgical emergency unit did not always work co-operatively with them and specialist nursing staff told us referrals from the ED were impeded.

We observed occasions when patients’ privacy and confidentiality was not maintained. For example, conversations held by staff at the desk in the children’s department could be overheard by patients and relatives in the waiting room opposite.

The holistic needs of the patients such as the need for refreshments were not always considered in a timely way.

The ED feedback on the Friends and Family Test was worse than the England average.

There was evidence of behaviours and cultures, which affected the way patient care was managed and the patient pathway through the department.

A clear governance framework was in place, although improvements to the service with regards to service performance and patient flow through the department had not been addressed.

However:

We observed staff provided compassionate care and the department had implemented changes to support vulnerable people, for example patients living with dementia or with a learning disability.

The percentage of patients waiting four to 12 hours from decision to admit to admission was better than the England average.

Staff felt supported and displayed resilience through team working and support from their leaders. The senior management team demonstrated a clear understanding of the issues facing the department.

Plans had been approved to expand the department and double the size of the resuscitation area. Staff worked collaboratively with other teams to receive and manage adult and paediatric major trauma patients.

Staff were confident to report incidents and encouraged to participate in departmental and trust wide meetings to share learning in a constructive way. The department undertook a range of clinical audits as part of the directorate clinical audit programme to show evidence of learning and service improvement.

Surgery

Good

Updated 9 May 2017

We rated this service as good because:

There was a safe number of staff with appropriate skills, training and experience to keep patients safe. The service used agency staff who were familiar with the service and its procedures. The hospital followed the escalation policy and procedures to manage busy times.

Staff planned and delivered patients’ care and treatment using evidence based guidance and audited compliance with National Institute Health and Care Excellence (NICE) guidelines.

Ward and theatre areas we visited were clean and tidy, we saw most staff following good infection prevention and control practices. Staff knew the trust’s process for reporting incidents. They received timely feedback from managers regarding reported incidents the lessons learned. There was strong multidisciplinary working across teams at the hospital so patients received co-ordinated care and treatment.

Nursing staff completed timely risk assessments for patients. If a patient became unwell, there were systems for staff to escalate these concerns. The hospital provided care to inpatients seven days a week. Staff ran an on call system with access to diagnostic imaging and theatres.

We saw staff treated patients with compassion and care. They were kind and treated them with dignity, and respect. There were systems to support patients with additional or complex needs. Patients felt informed and involved in their care. Patients and families said they would recommend the service to others.

Staff followed the trust’s governance processes to monitor the quality and risks of the surgical service. They completed audits and monitored patient outcomes, making changes to practice when necessary. Staff told us the leadership across the service was good and the senior team was visible and accessible. Staff had an annual appraisal and could access additional training to develop in their role. The trust had employed a falls safe training lead and falls had reduced from three serious patient falls a month to zero falls.

However:

Although we saw good practice with staff risk assessing patients at risk of developing pressure ulcers and obtaining pressure relieving mattresses, we did not see pressure relieving cushions used for identified ‘at risk’ patients.

The resuscitation trolley located in the cardiothoracic theatres had not been checked since mid-September 2016. This meant staff could not be assured the equipment was ready to be used and accessible

Nursing and midwifery staff did not achieve the trust 90% target in three of the six mandatory modules. Minutes from clinical governance meeting July 2016 showed the trust was aware and was taking actions to address the concern.

Intensive/critical care

Good

Updated 14 May 2014

Patients received safe and effective care. While staff recruitment and retention was recognised by the senior staff as an issue, the levels and skills of staff on a day-to-day basis were consistently managed. Clinical outcomes were monitored and demonstrated good outcomes for patients.

Patients and relatives told us the caring, consideration and compassion of staff was of a very high level. Considerable work had recently been undertaken to improve the responsiveness of the service to ensure patients were discharged when they were ready and delays were minimised. This also improved the responsiveness for pre-planned admissions following surgery to take place. The departments were well led and demonstrated a positive leadership and culture. A business case had been submitted to the trust board for future improvements for an increase in high dependency beds to meet the identified demand as the service sometimes runs at over 100% capacity.

Services for children & young people

Good

Updated 14 May 2014

We visited all the wards in the children hospital including the paediatric intensive care unit (PICU), the paediatric high dependency unit (PHDU) and the neonatal intensive care unit (NICU). We spoke to 45 members of staff. This included 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 and relatives, three children and two young people.

Parents, children, and young people were positive about the care and support their received. They told us they were kept informed and involved in making decisions. Staffing levels were considered when managing the number of beds available to be used. The trust was aware of areas were additional staff were required and they were actively recruiting to these areas. Staff told us they felt supported and the children’s hospital was a good place to work. There were systems in place to ensure children at risk of harm or considered to be of concerns were identified and protected if seen in the hospital. Staff were aware of how to report incidents and this information was monitored, reviewed and learning shared with the staff. There was an established governance system in place that included monitoring complaints, incidents, outcomes from audits and the adherence to national guidelines. Young people’s opinions and input was actively sought through the Young People's Executive. 

End of life care

Good

Updated 14 May 2014

Patients received safe and effective end of life care based on evidence based guidelines, national standards, and protocols. Staff were caring and motivated. They demonstrated commitment to meeting patients’ end of life needs and to supporting patients’ relatives at this time.

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

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

Outpatients

Good

Updated 14 May 2014

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

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

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

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