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We are carrying out checks at Nuffield Orthopaedic Centre using our new way of inspecting services. We will publish a report when our check is complete.

Reports


Inspection carried out on 9 August 2017

During an inspection to make sure that the improvements required had been made

We inspected the  Oxford Centre For Enablement inpatient ward on 9 August 2017; this was an unannounced focused responsive inspection in response to a Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR) notification concerning an incident that occurred on the 8 July 2017.

The rationale for this inspection was to follow up on the RIDDOR, which gave details of possible avoidable harm that had occurred to an inpatient, and to ensure care was being provided in a safe way for the current patients.

Therefore, CQC only inspected and gathered evidence relating to the safe care of patients through observation, staff interviews and evidence gathering.

We have not rated this service as this was an inspection, which focused on safe care in one area.

  • Areas of the ward were not secure placing patient at risk as some patients would be able to leave the ward and grounds without being witnessed. The trust has put plans in place to address the issues identified with entry and exit points and the main unlocked gate.
  • Patients’ records were predominantly electronic, however these were difficult to integrate and there was not a clear contemporaneous record of care.
  • Risk assessments were being completed on admission; however, these were not consistently being reviewed and updated particularly when there was a change with the patient’s conditions. Neither were risk assessments being used to ensure plans of care reflected the patient’s needs.
  • Deprivation of Liberty safeguard applications were being submitted in response to some recognised occurrences where people were being deprived of their liberty such as the use of pen release lap belts and unit’s tagging system. However, patients were on occasion being deprived of their liberty without due consideration being given to the need to submit an application to gain consent to deprive a person of their liberty such as the use of bedside rails.
  • There was a lack of evidence that formal mental capacity assessments were being completed and documented when a patient was considered to lack capacity.
  • Staff were working flexibly to try to ensure there were sufficient staff to meet the patients’ needs, however to achieve this skill mix of staff was being impacted on.
  • Medical staff would place people under formal one to one supervision if they assessed them to be at risk. Other staff would place patients under intermittent one to one supervision if they felt the patient’s behaviour was placing them or others at risk. There was no clear process for this and no criteria therefore staff were at risk of unintentionally depriving patients of their liberty.

However:

  • Staff were clear about their responsibility to report incidents and how to do this. There was also a process to feed back the outcomes and required actions from any investigations.

There were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Review the standard of record keeping ensuring each patient has a contemporaneous record of care, with a plan of care which reflects their needs, taking into account the assessment of risk associated with delivering the required level of care.
  • Ensure plans of care are reviewed on a regular basis and when there is a change to the patients’ needs to ensure they remain current and relevant to the needs of the individual patient.
  • Ensure mental capacity assessments are completed and documented for all patients considered not to have capacity. Where a patient lacks capacity, consideration must be given to what would be in the patient’s best interest and if they are to be deprived of their liberty, safeguards required by legislation must be put in place.
  • Monitor and review the staffing levels on the inpatients ward to ensure they are at the required level with the correct skill mix to meet the assessed needs of the patients.
  • Ensure planned work to improve the safety of the unit is completed in a timely way.
  • Implement clear guidance and criteria for staff to follow when considering placing patients under one to one supervision.
  • Ensure that all aspects of the duty of candour regulations are adhered to and conversations are clearly documented.

In addition the trust should:

  • Ensure there is a clear system in place which is understood by staff to monitor application for Deprivation of Liberty safeguards to track both the application and the expiry dates of any such applications to ensure patients are not unlawfully deprived of their liberty.
  • Ensure the work to change control systems or the entrance and exit points of the unit, is completed in the agreed time scale.
  • Review the security control measures in place for all the gates that lead from the inpatient ward garden area to help ensure it is a safe place for patients to roam.
  • Take action to ensure the conservatory is a safe area for patients to use when it is raining.
  • Take account to ensure all staff are aware of the importance of closing and securing all doors assessed as needing to be shut for patient safety reasons.
  • Implement a system to ensure the unit is secure and safe out of hours.
  • Ensure staff are up to date with their mandatory training.
  • Consider the introduction of clear guidance as to when a patient becomes a risk and the use of the tagging system should be used for their own safety.
  • Ensure there is sufficient medical cover to provide a safe service.

Professor Edward Baker

Chief Inspector of Hospitals

Inspection carried out on 25-26 Feb and 2 March 2014

During a routine inspection

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.