The Care Quality Commission
  • Community
  • Community healthcare service

Archived: Oxford Health NHS Foundation Trust - HQ

Overall: Good read more about inspection ratings

4000 John Smith Drive, Oxford Business Park South, Oxford, Oxfordshire, OX4 2GX (01865) 901000

Provided and run by:
Oxford Health NHS Foundation Trust

Important: This service was previously managed by a different provider - see old profile
Important: This service is now registered at a different address - see new profile

All Inspections

Other CQC inspections of services

Community & mental health inspection reports for Oxford Health NHS Foundation Trust - HQ can be found at Oxford Health NHS Foundation Trust. Each report covers findings for one service across multiple locations
Read inspection report

28 March 2018

During an inspection looking at part of the service

This service is rated as Good overall. (Previous inspection 7, 8 & 9 November 2016 – Requires improvement overall)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services well-led? – Requires improvement

We carried out an announced focused inspection at Oxford Health NHS Foundation Trust - HQ on 28 March 2018. We undertook this inspection to follow up on breaches of regulation following the inspection in November 2016. We inspected the safe, effective and well led domains during this focussed follow up inspection.

At this inspection we found:

  • The provider had reviewed the governance arrangements for all identified concerns from the previous Care Quality Commission inspection report and implemented changes.
  • Staff training for basic life support had been completed, but there were still some gaps in chaperoning training for drivers/receptionists. There were also gaps in safeguarding training for GPs.
  • The provider showed us their National Quality Requirements data (a key performance measure for out of hours services) for April 2017 to February 2018, which demonstrated some improvements on the previous reported figures although they remained below target for some indicators.
  • The provider had undertaken a recruitment programme to improve staffing levels and ensure enough clinical staff were in post.
  • The provider had introduced blank printed prescription tracking and monitoring systems since the last inspection, although we found these were inconsistently applied across different sites.
  • Cleaning schedules and spot checks had been improved to ensure infection control risks were minimised.
  • Recruitment documentation had been reviewed to identify any gaps in stored information. Disclosure and Baring Service (DBS) checks for GPs had improved and those identified as not yet in receipt of a DBS check had been risk assessed.
  • Calibration of blood glucose monitoring equipment had been implemented although staff required further training on when a calibration was required.
  • The Controlled Drugs (CD) order book at one of the sites (Oxford City) had still not been completed appropriately when they received CD stock into the base.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Continue to review and improve staffing levels with a view to achieving the 98% target for session fulfilment.
  • Review calibration of blood glucose monitors and ensure staff are aware of best practice guidelines for use.
  • Review arrangements for monitoring and recording chaperone training to ensure it has been completed for all required staff.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

7 to 9 November 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at of the Out of Hours services at Oxford Health NHS Foundation Trust – HQ between 7 and 9 November 2016. Overall the service is rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and a system in place for recording, reporting and learning from significant events.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • The provider offered a wide range of training opportunities and maintained records of training completed by staff. However, 11 staff had not completed training in basic life support and not all receptionist/drivers had received chaperone training.
  • There was a system in place that enabled staff to access patient records, for example the local GP and hospital, with information following contact with patients as was appropriate.
  • The service proactively sought feedback from staff and patients, which it acted on.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. There is an active review of complaints, how they are managed and responded to and improvements are made as a result. People who use services are involved in the review.
  • The service worked proactively with other organisations and providers to develop services that supported alternatives to hospital admission where appropriate and improved the patient experience.
  • The provider had good facilities and was well equipped to treat patients and meet their needs. The vehicles used for home visits were clean and well equipped.
  • The provider was aware of and complied with the requirements of the duty of candour.
  • There was a comprehensive system in place to keep patients safeguarded from harm. This included an additional prompt at the end of the consultation record to remind GPs and advanced practitioners to consider if the consultation required referral or consideration as a safeguarding event. There was a clear leadership structure. Communication channels were open and staff felt supported by management.
  • Patients’ care needs were assessed and delivered following a two stage assessment process which prioritised need. The service was meeting some of the National Quality Requirements and had plans in place to address the areas where they were not.
  • At the time of inspection there were not enough clinical staff in post to ensure the provider met national quality requirements (performance standards). In 2015 the provider had met these standards consistently. However, this performance could not be maintained in 2016 due to shortages of GPs and practitioners. A recruitment programme was underway and there was evidence that this was proving successful with new staff appointed to start in December 2016 and January 2017.
  • The provider had systems in place to identify, assess and manage risk but the systems were operated inconsistently. Some risks associated with managing prescriptions and cleanliness of treatment facilities had not been identified during monitoring of the service.
  • The provider had identified the risk associated with staff shortages and had taken steps to recruit new staff and manage sickness levels. However, the actions taken had been time consuming and staff recruitment was still being pursued at the time of inspection.
  • The provider had not obtained evidence of some recruitment checks and mandatory training in a timely manner.

The areas where the provider must make improvement are:

  • The provider must ensure governance processes and systems are consistently applied in a timely manner to assess, monitor and improve the quality and safety of the services provided.

The areas where the provider should make improvement are:

  • Ensuring calibration and checking of blood glucose meters is carried out in accordance with the manufacturer’s specification at all times.
  • Ensure the controlled drugs receipt log at Oxford City base is signed when controlled drugs are received into stock.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice