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Inspection report

Date of Inspection: 14 September 2010 and 11 July 2011
Date of Publication: 3 February 2011
Inspection Report published 3 February 2011 PDF | 320.95 KB

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The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Not met this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

We reviewed all the information we hold about this provider, carried out a visit on 14/09/2010, 11/07/2011, observed how people were being cared for, looked at records of people who use services, talked to staff and talked to people who use services.

Our judgement

The trust has a range of measures in place to assess and monitor the quality of patient care it provides. It has worked to improve the quality of information received at board level to enable decision making and quality assurance. Serious incidents are also investigated thoroughly and action plans developed.

The paediatric cardiac review and the trust’s own internal review has identified issues with clinical governance structures, reporting arrangements and the quality of information produced to monitor the quality and safety of patient care across the organisation. This review also found the committee structure for clinical governance to be complex. Minutes from key meetings showed that when issues are identified and discussed, there was limited reference to what action would be taken and by whom. Overall, it was not clear that there was a systematic process in place to show how actions are implemented, followed-up and their impact monitored.

Overall, we found that the Churchill Hospital was not meeting this essential standard and action needs to be taken to become compliant.

User experience

The trust has systems and processes in place for governance, patient safety and risk management. The trust has conducted an internal review of clinical governance processes which was reported to the board in May 2010. The review found that there were too many committees involved in governance and that there was a lack of clarity around the remit of these committees. Reporting systems were also found to be overly complex. Similarly, an independent review of paediatric cardiac care in July 2010 found risk reporting structures to be complex. The report stated that “there is a significant risk that key risks get missed and are not escalated in a timely manner to ensure appropriate action is taken”. The clinical governance systems were found to lack clarity and transparency.

There have been significant changes to senior executive appointments at the trust over the past twelve months. This includes the chief executive officer, medical director, finance director and some non executive directors. The board has recently reviewed and developed a new clinical management structure which was implemented in November 2010.

The board has also reviewed and changed the format and amount of information it receives. Board minutes identify that the information being presented did not always provide accurate and pertinent information for quality assurance. In the 2009/10 trust quality account, Oxfordshire Primary Care Trust commented that it would be beneficial if there was more detailed information. It stated that it required clearer information on what the trust does well and where improvements are needed. As commissioners, the PCT has a role in managing the performance of the trust. The trust has worked to address this concern and more recent minutes of board meetings indicate that information provision about the quality and safety of patient care has improved.

As part of this review, minutes of the trust’s key governance and management committees were reviewed. At the time of this review, the care quality board was a key committee in this structure. This group had clinical and operational leadership and its role was to review the quality of care delivered against key measures. This included infection control, serious incidents and other patient-reported outcomes. The group had a wide remit and minutes showed that many issues were discussed. There was however limited documentation of how issues will subsequently addressed and actions monitored. There also appeared to be little systematic review and follow up of issues from meeting to meeting.

At the time of this review, the governance committee had a key role in overseeing governance and provide assurance to the board. This committee met quarterly. There was a lack of clarity about how these two committees work together and how actions were assigned and monitored and their impact assessed.

Following the review of paediatric cardiac services (commissioned by the strategic health authority) and the external review of governance arrangements commissioned by the trust, the trust board approved a revised sub-committee structure at its meeting on 7 October 2010. The new committee structure was implemented on 1 January 2011. The board now has 4 subcommittees: the board in committee, the quality committee (to replace the governance committee), the audit committee and a remuneration and appointments committee.

Risk management and incident reporting

The trust has processes in place to manage risk. There is a corporate risk management team and an incidents, claims and complaints committee. These committees receive and analyse incidents and create reports to be presented to the executive committees, including the trust board. They also have a remit to ensure that actions are taken following serious incidents.

The trust’s internal staff safety survey found that 43% of staff who responded (1789 people) had not reported an incident over the past 12 months. The National Patient Safety Agency views a hig

Other evidence

Unspecified