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Inspection carried out on 19 - 21 November 2018

During a routine inspection

During this inspection we inspected the core services of gynaecology and surgery. We rated the gynaecology services as requires improvement and the surgery as good. In reaching our final rating for this location we have taken in to account the ratings for the core service medicine and end of life care also provided at this location, which were not inspected on this occasion.

Our rating of services stayed the same. We rated them as good because:

  • Incident reporting systems were in place and there was a culture of reporting, investigating and learning from incidents.
  • Staff kept detailed records of patients’ care and treatment. Detailed risk assessments were carried out for patients who used the services and risk management plans were developed in line with national guidance. There were effective arrangements in place to safeguard patients from abuse and mitigate the risk of it happening.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Patients said they were involved in decisions about their care and that staff considered their emotional well-being, not just their physical condition.
  • The service followed best practice when prescribing, giving and recording medicines and patients received the right medication at the right dose at the right time.
  • Staff assessed and monitored patients regularly to see if they were in pain and had enough to eat and drink.
  • The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services.


  • In general, services provided care and treatment based on national guidance and managers monitored the effectiveness of care and treatment and used the findings to improve them. Most leaders had the skills, knowledge, experience and integrity they needed to fulfil their roles.
  • However, recent organisation changes meant there were new leaders at directorate and divisional levels for the gynaecology service. While these teams were working to ensure there were clear reporting structures and a sustained level of scrutiny to ensure they were delivering a quality service where risk were known and managed this was still under development. Therefore, it was not possible to fully assess the effectiveness or impact of the governance and risk management processes.
  • There were structures, processes and systems of accountability to support the delivery of the strategy and sustainable services. However in the gynaecology services audits and quality outcomes conducted at a local and divisional level to monitor the effectiveness of care and treatment were not always effective in identifying areas for improvement.
  • Evidence was not provided to show staffing levels were always planned, implemented and reviewed to keep people safe.
  • Staff did not always receive training identified as necessary for their role.

Inspection carried out on 25-26 February and 3 March 2014

During a routine inspection

The Churchill Hospital first opened in 1942 during the war as an American Hospital; it was taken over in 1946 by Oxford City Council and integrated with the John Radcliffe Hospital in 1993. There are 217 in-patients beds, 8 critical care high dependency beds, 10 theatres, day care and outpatient facilities. The Churchill Hospital in Headington is the site of the Oxford Cancer Centre and a centre for renal and transplant services, medical and surgical services, oncology, dermatology, haemophilia, infectious diseases, respiratory medicine, medical genetics, palliative care and sexual health.

To carry out this review of acute services we spoke to patients and those who cared or spoke for them. Patients and carers were able to talk with us or write to us before, during and after our visit. We listened to all these people and read what they said. We analysed information we held about the hospital and information from stakeholders and commissioners of services. People came to our two listening events in Banbury and Oxford to share their experiences. To complete the review we visited the hospital over two days, with specialists and experts and carried out an unannounced visit. We spoke to more patients, carers, and staff from all areas of the hospital on our visits. The regulatory activities diagnostic and screening procedures, surgical procedures, treatment of disease, disorder or injury were inspected.


Staff were positive about working at the hospital they said it was a supportive environment in which to work. Where staffing levels were a concern wards were able to use agency and bank staff to maintain safe staffing levels. In cases where this was not possible beds would be closed. The hospital was actively recruiting to vacate posts.

Cleanliness and infection control

The hospital was found to be clean. Some areas of the hospital were found to be old, tired and worn. Hand washing facilities were readily available as was hand cleansing gel. Staff cleaned their hands between patients and this was supported by the feedback given by patients. It was observed that staff observed the hospital bare below the elbow policy. Infection control nurses were available to support staff and audits were undertaken to monitor practice. The trust’s infection rates for Clostridium difficile and MRSA lie within a statistically acceptable range for the size of the trust. In the last three months there had been no incidents of MRSA cases at this hospital.

Inspection carried out on 25 February 2014

During Reference: not found