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Inspection Summary


Overall summary & rating

Good

Updated 14 May 2014

The Nuffield Orthopaedic Centre, Oxford, is the smallest hospital in the Oxford University Hospitals NHS Trust, with 160 beds, and serves a population of around 655,000 people. It provides specialist acute medical and surgical services in orthopaedics, rheumatology and rehabilitation to the people of Oxfordshire. The hospital also undertakes specialist services such as the treatment of bone infection and bone tumours, limb reconstruction and the rehabilitation of those with limb amputation or complex neurological disabilities. The Nuffield Orthopaedic Centre site includes the Oxford Centre for Enablement and the Botnar Research Centre.

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
  • Surgical procedures
  • Treatment of disease, disorder or injury

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 Oxford and Banbury to share their experiences. To complete the review we visited the hospital over three days, with specialists and experts. We spoke to more patients, carers, and staff from all areas of the hospital on our visits.

The services provided by the Nuffield Orthopaedic Centre were good. There were some areas for improvement within services. These related to the documentation about patients’ care needs in care records to ensure that staff had suitable information. Considering the impact of this across the services, the hospital did not meet the regulations relating to records. There was also room for improvement in the effective dissemination of learning from incidents which occurred in other areas of the hospital or the Trust, to ensure that these did not occur again. Local feedback of learning and actions to be taken following incidents was carried out within the hospital.

The staff within the hospital felt proud to work there, although there was a feeling of being distanced from the trust. Some staff reported positive changes since the hospital became part of the trust. However, there was significant discontent with some senior clinicians at the hospital who reported poor engagement from the senior management of the trust.

Patients’ views and experiences were a key driver for how services were provided. Patients said they felt safe and well cared for. Staff worked in multidisciplinary teams to co-ordinate care around a patient.

The hospital worked towards achieving national targets in relation to waiting times, cancelled operations, and delayed discharges. There was acknowledgement that there was limited access to suitable placements in the community and that this had an impact on the access to services.

Staffing

The hospital monitored and planned staffing to meet patients’ needs. We observed that there were sufficient staffing levels. However, some staff reported that they did not always have time to spend with patients to allow them to express their concerns about care and treatment. Bank and agency staff were used to supplement the staffing of wards where vacancies existed. Staff generally found that bank and agency staff were well skilled and able to undertake the work required of them. Planning of staffing to meet patients’ needs had been used to increase the number of staff on wards. Divisional reports showed that the staff vacancy rate ranged from 7.8% to 13.25% in different areas of the hospital. There was a focus on recruitment within the trust as a whole, although there were reports of difficulties in recruiting staff due to the high cost of living within Oxford.

Cleanliness and infection control

There were systems and processes in place to ensure good cleanliness and infection control within the hospital. The hospital was clean and staff observed good infection control practices. Staff wore appropriate personal protective equipment when delivering care to patients and suitable hand washing facilities and hand gel were readily available.

The number of methicillin resistant Staphylococcus Aureus (MSRA) bacteraemia infections and Clostridium difficile infections attributable to the hospital was with the acceptable range for a hospital of this size. The number of patients with a catheter who contracted a urinary tract infection was similar to the average for England in the last 12 months.

Inspection areas

Safe

Good

Updated 14 May 2014

We found that services at the hospital were safe and the hospital had a good safety record. Staff had a good understanding of how to report incidents. Where incidents occurred, appropriate investigations followed and learning was identified. Although staff were aware of incidents and learning, there was evidence that the learning from incidents was not always disseminated effectively to ensure that actions were taken to prevent reoccurrence. In some cases action plans had not been completed within set timescales following incidents.

Monitoring of safety was apparent in the hospital. Information about safety was available on wards for staff, patients, and visitors. This included the last instance of patient falls or pressure ulcers were visible in ward areas. There were systems in place to ensure safety within operating theatres.

While we saw that people received good care and treatment, there were areas for improvement in the completion of patient records, which had the potential to put people at risk. Records did not always provide sufficient information to staff to ensure that people received the care that they needed. This was on both medical and surgical wards.

There were sufficient staffing levels which were planned to meet patients’ needs. Staff recorded staffing levels against patient needs for each shift. We saw that this had been used to increase the staffing levels on medical wards where some staff reported they did not always have sufficient staff. The hospital experienced difficulties in recruiting and retaining staff due to the cost of living within the area.

Effective

Good

Updated 14 May 2014

Outcomes for patients were good. Patient reported outcome measures (PROMs) for hip and knee replacement surgery showed no evidence of risk and good reported outcomes for patients. The trust standardised in-hospital mortality rates for the musculoskeletal group was much better than expected, when compared with other trusts. National guidelines and best practice were applied and monitored. Staff worked in multidisciplinary teams to co-ordinate care around a patient. 

Caring

Good

Updated 14 May 2014

During our inspection we observed people receiving compassionate care. Patients were treated with dignity and respect. Privacy was maintained in all areas, curtains were drawn around patient beds when care was provided. Patients confirmed this.

Patients said they were involved in making decisions about their care and treatment. However, there was little documentation in records to show this.

Information was available to patients and their families in suitable formats to meet their needs. There were facilities available to provide interpretation services for patients whose first language was not English. Examples were given of when these services had been used within the hospital.

Responsive

Good

Updated 14 May 2014

The service was responsive to people’s needs. However, there were some areas for improvement regarding the documentation in records of patients’ individual needs, including whether they had been identified or assessed as being vulnerable or living with dementia or a learning disability.

Patients said when they needed help staff responded to call bells quickly.

The hospital worked towards achieving national targets in relation to waiting times, cancelled operations, and delayed discharges. There was acknowledgement that there was limited access to suitable placements in the community and that this had an impact on the access to services. This also had an impact on people leaving hospital. However, staff told us that routine discharges from the hospital were managed efficiently and effectively. Patients received appropriate information about discharge from hospital.

Patients were aware of complaints procedures and felt confident that their concerns would be taken seriously. The hospital routinely captured feedback using the friends and family test. There was evidence of this being monitored and discussed within the hospital.

Well-led

Good

Updated 14 May 2014

There was a clear trust vision and a set of values. Many staff did not know what the vision and values were but portrayed similar values and a passion to provide excellent patient care. Staff said they were proud of the work they did. However, they felt distanced from the running of the wider organisation. This was particularly clear in the Oxford Centre for Enablement (OCE) where the matron was based on another hospital site within the trust.

Some staff reported positive changes since the hospital became part of the trust. However, there was significant discontent with some senior clinicians at the hospital who reported poor engagement from the senior management of the trust. They reported decisions being taken at a trust level without the engagement of the consultant body. There were also reports of poor morale. In other areas there were reports that clinicians felt able to call for senior help when required. Nursing staff said they felt supported by their line managers.

Patients’ views and experiences were a key driver for how services were provided. Patients said they felt safe and well cared for. Patients reported being involved in booking appointments. There was an established patient involvement group, which met to discuss what improvements could be made to the site for the benefit of patients.

There was a clear governance structure with reporting lines from departments through directorates and divisions, ultimately to the trust board. However, there was a lack of clarify by staff around lines of accountability, cross divisional and cross hospital working. 

Checks on specific services

Outpatients and diagnostic imaging

Good

Updated 14 May 2014

Patients received safe and effective care delivered by sufficient numbers of staff with relevant training. The triage team ensured that patients were assessed and each appointment was booked to ensure a smooth transition to investigations and treatment within the hospital.

We spoke with eight patients and most were complimentary about the service. Patients were well informed, had their appointments booked in a timely manner and did not wait long to be seen. All patients’ records were computerised and accessible. The environment was clean and spacious and the department was well led.

Medical care (including older people’s care)

Updated 27 March 2018

This was a focused inspection with two domains being reviewed therefore there is no overall rating for this service. This was because this inspection was to follow up on concerns identified at the previous inspection. To ensure that the previous risks identified had been addressed, and patient care was safe and to review the organisation and leadership of the unit. The two domains safe and well led have been rated as requires improvement.

  • There was variation in the cleanliness of the unit; some areas were not sufficiently clean, disposable curtains were not always changed every six months as per unit protocol, clinical cleaning at the weekend was inconsistent and hand hygiene audits were not submitted monthly as required by the trust.

  • The work to update and change existing door locks, to ensure patients using the service were safe, was still not complete even though the completion date for the work was October 2017.

  • There was not an effective system to manage and monitor maintenance issues. There were some safety tests for equipment due in 2016 that had not been completed.

  • There were some equipment items stored alongside the emergency equipment that were out of date meaning they could have been inadvertently used.

  • Staff were not routinely trained in all key areas of safety. Mandatory training rates were low in some key areas for medical staff and some areas of safety were not deemed essential for staff working in the unit. The unit had started to use a new electronic patient observation and escalation system without staff receiving the full training.

  • Staff we spoke with were not familiar with the trust’s sepsis pathway.

  • There were no personal evacuation plans for patients and there had been no reassessment of the fire evacuation risks following the decision to change the way the security arrangements for the unit.

  • The nurse and medical staffing vacancies were significant with little improvement since the last visit despite recruitment efforts. Although the trust had reduced the risk to patients by reducing the number of beds in October 2017.

  • Although the organisation of patient paper records were found improved overall, it was still difficult to link them with the electronic system, and therefore a contemporaneous record was not available.

  • Pre-printed care plans had not been reviewed to ensure they were reflective of the latest local and national guidance; there was also inconsistency in the staff evaluations and signatures.

  • Managers had not created an opportunity for a multidisciplinary team event for the last two years.

  • We were not assured that the monitoring of the service was effective, as the team had not recognised the risks we identified.

  • A philosophy and vision paper was produced in November 2017, but there was no evidence who had been engaged in agreeing it or who wrote it. There were no shared values or strategy displayed.

  • The rating of risks was not consistent or always accurate and some were rated lower than the impact would indicate, for example the nurse staffing vacancies, which had led to bed closures.

  • We were not assured that risks were escalated appropriately for the senior teams to consider.

  • Even though staff worked with patients and their relatives on an ongoing basis, there was no local mechanism for patient and relative feedback other than the trust wide friends and family test.

  • Staff were not familiar with the term Duty of Candour and its formal requirements.

However:

  • There had been good progress in developing a more effective method of tracking and managing the patients’ pathway via the daily quality board reviews.

  • Staff now followed the trust policy and assessed their patient’s capacity using the Mental Capacity Act. There was documentary evidence to support this.

  • Patients were risk assessed for their suitability to use bedside rails on their initial admission to the unit.

  • The ward kitchen doors were shut securely for safety.

  • The garden area was now secured with keypad locked gates; the codes were restricted to OCE staff.

  • The patient tagging system had been repaired and there was a 24hour helpline in case of breakdown.

  • Staff were complimentary of the unit’s local leadership and the team in the unit.

  • Staff were clear about their responsibilities to report incidents and how to do this. There was a process for feedback on incidents, actions and learning.

  • Staff managed and administered medicines safely.

  • The leadership team were involved in various research projects for improving patient outcomes.

Surgery

Good

Updated 14 May 2014

The hospital had a good safety record, with only one serious incident reported in the last 12 months. There was evidence that this incident, which resulted in the death of a patient, had been thoroughly investigated and learning had been identified. Although, the trust had formal processes in place to disseminate learning from incidents, this was not effective because staff were not clear about the learning from this incident.

All of the patients we spoke with were effusive in their praise for the staff at the hospital, with comments including: “nothing is too much trouble” and “this is the best hospital I have been in”. Staff were caring, dedicated, and proud to work at the hospital. It was considered a good place to work by many staff, who felt well supported by senior clinicians and local management. Staffing shortages for nurses and healthcare assistants presented an ongoing challenge and there was regular use of temporary staff. Staff expressed frustration about patients’ discharge being delayed because of a lack of suitable alternative hospital beds or support in the community. This sometimes led to ‘bed blockages’ and cancelled operations. Despite these challenges, staff believed that they provided a good quality of patient care and discharge arrangements were proactively and effectively planned.

There was significant discontent among the consultant body, who were concerned about the culture and the management style of senior management. There was unhappiness about a lack of engagement with clinicians and a belief that decisions were being taken without consultation with clinicians, for financial reasons, and which were detrimental to patient care. Some senior staff felt they could not speak out or did not feel that they were listened to.