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We are carrying out checks at Horton General Hospital using our new way of inspecting services. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Good

Updated 14 May 2014

Horton General Hospital is an acute general hospital in Banbury in North Oxfordshire. The hospital has a long history from first opening with two wards in 1872. It became part of the Oxford University Hospital NHS Trust in 1998. It provides a range of services including an emergency department (A&E), general surgery, acute general medicine, trauma and orthopaedics, maternity services, a children’s ward and special care baby unit (SCBU), critical care, coronary care, a cancer resource centre, and dialysis. The hospital serves a catchment population of around 150,000 people in and around North Oxfordshire and neighbouring communities in south Northamptonshire and south east Warwickshire. There were 248 inpatient beds and the hospital saw around 120,000 patients as inpatients each year. The hospital arranged in the region of 90,000 outpatient appointments each year and saw 36,000 people each year in the emergency department.

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. We spoke to more patients, carers, and staff from all areas of the hospital on our visits.

The services provided by Horton General Hospital were delivered to a good standard. Patient care in all the departments and services we visited was delivered safely, by caring staff who were well led. The hospital was delivering effective care although needed to review how patients in critical care were supported safely by consultants with the relevant training. Staff told us they were well supported by one another and their managers. The overriding comment from the nurses we met was them telling us the reason they came into work each day was the support they gave one another. Departments, wards and services were well led at a local level, but there was some concern around overall leadership of the hospital as staff told us they felt there was no one with overall responsibility. This was because the trust worked in directorates, and different senior staff were responsible for different parts or divisions of the hospital. Staff told us on occasion an issue in one department could impact another and it was sometimes hard to find a resolution without a general manager.

A number of people from the local community we met at our listening event in Banbury said they were not consulted by the trust about changes made to the provision of services. People, patients and staff were concerned specifically about the removal of emergency surgery from the hospital. The main concern of staff was feeling their voice was not heard by the trust. The trust told us about the communication exercise undertaken to inform all internal and external stakeholders about the decision and rationale to remove emergency abdominal surgery from the hospital. This involved meetings with the Community Partnership Network.

Staffing

The hospital was and had been actively recruiting staff, particularly to nursing posts. Some staff were concerned about the future of the hospital and rumours or discussions about its future. They said they knew this had deterred some staff from actively looking to work at the hospital and meant there was a high level of locum staff at times. Most staff felt the hospital was, however, well-staffed most of the time. Nurses and doctors said they felt they had enough time to spend with patients, although they said there could always be more. Nurse managers said they usually had time for their managerial duties, but would step in to direct care provision when the department or ward was short-staffed. Some staff said training was usually the first thing postponed if their area was short-staffed, but otherwise the training completion rate was high.

Cleanliness and infection control.

The hospital was clean on both our announced and unannounced visit. Staff followed cleaning schedules, paying attention to hard-to-reach areas, and most areas were organised to make cleaning as efficient as possible. We observed good infection control practices among staff. Staff were wearing appropriate personal protective equipment when delivering care to patients. There was a relatively good provision of hand gels across the site and we saw staff using them and asking patients to do the same. The number of MSRA bacteraemia infections and Clostridium difficile infections attributable to the hospital were within the acceptable range for a hospital of this size.

Inspection areas

Safe

Good

Updated 14 May 2014

Services at the hospital were safe. Staff were trained and responsive to any signs of abuse and avoidable harm. They were open and transparent when things went wrong, investigated them and made changes to avoid recurrences. The hospital was clean and infection control protocols were followed. Medicines were managed safely. Staffing levels were acceptable and departments responded well to busy times.

Emergency services were safe, although some aspects of the provision for children did not follow the guidance for paediatric emergency care. This included challenges from the environment, which had been recognised by staff. The majority of training was delivered on time, although there was a lack of specific training for staff in A&E for supporting people with dementia. Maternity and children’s services were safe, and staff followed best practice guidance. End of life care was delivered well across the hospital and linking with community services to follow best practice. Medical and surgical care was delivered to ensure patients were safe. Staff said they were encouraged to report anything they felt was not safe and it was addressed.

The critical care service provided excellent care with good outcomes. But the service was not meeting guidance in relation to medical cover. There were experienced anaesthetists and consultants attached to the unit, but not all had critical care training. There was no critical care Outreach service in the hospital, although we were told this was being discussed and the service could be reintroduced.

Patients with cognitive impairments were supported to make decisions, but when they were not able to, the requirements of the Mental Capacity Act 2005 and multidisciplinary decisions acting in people’s best interests were followed. Otherwise, patients and their partners were involved in decisions and made their own choices.

Effective

Good

Updated 14 May 2014

Outcomes for patients were good and the hospital performed well when measured against similar organisations. National guidelines and best practice were applied and monitored, and outcomes for patients were good overall. Pain management was done well, and patients were supported with good hydration and nutrition. Staff worked in multidisciplinary teams to co-ordinate care around a patient. End of life care was integrated across the hospital and with community services. Staff were supported to be innovative and were continually looking to improve services. Most mandatory training and appraisals were on track to be completed annually. New mothers were well supported and children and young people’s services were effective.

Caring

Good

Updated 14 May 2014

During our inspection, we observed almost all staff were caring and patients confirmed this, saying that staff were considerate, and treated them with kindness and respect. Patients and carers coming to the maternity and children’s services said that staff were welcoming, caring, and kind. A&E staff, outpatient staff and ward-based staff were praised for their kindness. Staff in the critical care team provided good care and emotional support. End of life care, which was provided across the hospital where needed, was caring, professional and supportive to patients’ choices.

Support for patients with mental health needs, particularly in the A&E department, was not always adequately covered. This had improved recently, but out-of-hours or weekend provision was limited.

Responsive

Good

Updated 14 May 2014

The hospital supported vulnerable patients well, to ensure care was delivered in their best interests. Discharge arrangements were usually managed well. Bed occupancy at the hospital was sometimes at a level that had an impact on the quality of care, and caused the A&E department to miss waiting-time targets for patients. The critical care unit occasionally had not met discharge targets, as there were sometimes no beds available into which to move patients who were recovering. Patients were sometimes delayed by their discharge into community care not being arranged in good time by other providers. There had been changes made to provide patients ready to go home with support in the day-case lounge to expedite discharge and release beds to the ward.

The trust said it had consulted with local people about changes at the hospital. However, people we met particularly at our Listening Event in Banbury said they were not consulted, and specifically not about the cancellation of the provision of emergency surgery at the hospital. The trust told us about the communication exercise undertaken to inform all internal and external stakeholders about the decision and rationale to remove emergency abdominal surgery from the hospital. This involved meetings with the Community Partnership Network.

Well-led

Good

Updated 14 May 2014

Staff told us they felt the hospital was well-led at a local departmental level. Staff were supported by their peers and managers to deliver good care and to support one another. Staff said they felt proud to work at the hospital, but did not feel at all times they were included and consulted in plans and strategies by the trust. Some staff described this as feeling isolated.

There was a lack of support for some newly qualified midwives and some staff in the maternity ward felt morale was low. Most staff said, however, they had good appraisals with their managers each year and could discuss matters openly and had no fear of reporting concerns.

Checks on specific services

Maternity and gynaecology

Good

Updated 14 May 2014

The maternity unit at the Horton provided safe care which was tailored to the needs of women receiving pre- and post-natal care.

Women received care from caring, compassionate and skilled staff. We received positive comments from women and their families about the care and support they received. They were involved in decisions about their care and received emotional support as required.

The unit was clean and staff followed the internal procedures for hand washing. Hand gels were available at different points and visitors were encouraged to use them. Staff had completed training in infection control to ensure women and babies were protected from the risk and spread of infection.

There were systems in place to record near misses and other events and the staff were aware of their responsibility to record and report these incidents. There was evidence that learning from incidents occurred and action plan developed.

People were safeguarded from the risk of abuse. Staff had received training in safeguarding and were aware of the process to report any such issue. This ensured patients were not put at risk as appropriate safeguards were in place.

Most practice was in line with national guidelines. There were concerns about the lack of support for newly qualified midwives which may impact on care delivery. The labour delivery suite had been without a manager and there was a lack of succession planning.

The service was well-led. There were clinical governance strategies and regular meetings which looked at development of the service. Staff felt supported within the ward and units; however, they told us they felt disconnected from the wider organisation.

Medical care (including older people’s care)

Good

Updated 14 May 2014

The hospital provided safe care. National tools were used to measure risks to patients and action was taken to address identified risks. Staffing levels were regularly monitored to ensure wards and departments were adequately staffed. Integrated care pathways for inpatients with diabetes were still being devised. Actions included a business case to bring diabetes inpatient specialist nurse numbers in line with the national average as well as early and comprehensive standardised assessments.

Staff were caring. Patients spoke highly about the care they received and the kindness and helpfulness of the staff. Staff worked effectively and collaboratively to provide a multidisciplinary service for patients who had complex needs. Patient views and experiences were sought by the hospital, by the provision of quality questionnaires, and the responses were fed back to staff on the wards. The hospital demonstrated openness to engage with patients and listen to their feedback to improve the services provided.

Urgent and emergency services (A&E)

Good

Updated 14 May 2014

The A&E department at The Horton General Hospital provided overall good safe care. The department had qualified and experienced staff with strong local leadership and direction. Patients told us they felt safe at the department. Systems and processes worked to keep people safe and give them the most appropriate care and treatment. Staff were caring and compassionate. Patients said their privacy and dignity was preserved and they felt treated as individuals.

Staff were dedicated to their patients and their service. They were committed to making improvements and listening to patients. There were few complaints made to the service, but those that were made were addressed and learned from. There was an open culture among staff where any care or treatment or avoidable incidents were discussed and ways to improve were recognised and implemented. The morale in the department was affected, however, by uncertainty about the future of the hospital. Staff felt this was not helping with local recruitment of nursing staff.

Patients we met described the service as “excellent”, said: “I have no complaints. They have been absolutely wonderful”, “I feel treated like a person here and like I really matter to these staff”, and: “I’ve been here a number of times and with my kids too, and the care has been first class. Nothing but praise for these staff. They work really hard and it’s not always easy for them.”

From raw data sent to us by the trust, we saw the department had breached the Government’s four-hour waiting time target on occasion. The data did not provide any detail of the reason for these breaches, but staff confirmed it was mostly due to their not being an available bed for the patient to be transferred into. There was no evidence this was due to staff in A&E not treating the patient in good time to facilitate their discharge. There had also been no specific increase in patient numbers attending A&E in the recent winter months. The busiest months in 2013 were in the summer period.

Surgery

Good

Updated 14 May 2014

There was consensus among patients, carers and staff that staff were dedicated and provided compassionate, empathetic care. Processes were followed to reduce any risks to patients undergoing surgical treatment. There were processes to ensure patients who moved to different wards received consistent and safe care and treatment. Staff made use of the language line facility and interpreters to ensure patients had good understanding of their treatment and were able to make informed decisions. Staff had a good understanding of the Mental Capacity Act 2005 which meant patients received the appropriate support to be able to make their own decision, or where required decisions involving appropriate people were made in the best interest of the patient.

Generally, there was sufficient equipment available to meet the needs of patents. However, concerns were expressed about access to MRI imaging. Patients had to go to the John Radcliffe Hospital in Oxford to access MRI imaging; we were told that difficulties in arranging appointments meant there was a risk that some patients’ treatment would be delayed.

We saw good evidence of team working at ward and departmental level. However, with some of the clinicians, there was a feeling that despite being part of Oxford University Hospitals NHS Trust, the views and opinions of staff at Horton General Hospital were not always heard.

Intensive/critical care

Good

Updated 14 May 2014

Patients received care which was compassionate, dignified and delivered good outcomes. Clinical outcomes for patients were good. Mortality rates were below the national average and below the expected level for patients in a critical care unit. The caring and consideration of staff was excellent. The patients and relatives we spoke with praised the nursing and medical staff highly. Vulnerable patients were well supported and staff put the patient at the centre of their care.

The department was well-led at local and senior level and staff were supported and proud of their work. There were some issues with patient discharge not being timely or being delayed, but this was due to pressures on beds elsewhere in the hospital. On a national level, this problem was not significant.

However, the critical care department was not meeting the guidelines in relation to medical cover. There were skilled and experienced anaesthetists and consultants attached to the unit, but not all had critical care training. The lead medical consultant was trained in critical care, but this was not their substantive post and they were not available at all times. There was no evidence this had resulted in patients being put at risk, but the arrangements did not meet the national guidelines for medical care in intensive care units.

Services for children & young people

Good

Updated 14 May 2014

We visited the children’s ward on a Tuesday and a Wednesday during the daytime and again on a Sunday afternoon and early evening as an unannounced visit. During these visits we talked with around nine patients and their relatives accompanying them. We spoke with staff, including nurses, doctors, consultants and support staff. We also received information from people who attended our listening events and from people who contacted us to tell us about their experiences. We collected comment cards from a designated box set up for our visit. Before our inspection we reviewed performance information from, and about the trust.

There was a multidisciplinary collaborative approach to the care and treatment of children across children's services in the hospital. Children's care and treatment was planned and well documented in the medical notes and nursing records in the patient's files. Staff across children’s services were confident the hospital had a reliable system to alert them to risk and implement improvements. Staff told us they could express their views in ward meetings and were “confident” they would be listened to by the organisation.

Children and young people received person centred compassionate care from staff in the children’s ward. We saw nursing staff delivered kind and compassionate care to a young child who was crying as their mother had gone home. Parents told us nursing staff had been “patient and kind.”

End of life care

Good

Updated 14 May 2014

Patients received effective and sensitive end of life care. Patients told us they felt safe with the staff and overall their needs were met. We were told medicines were prescribed to control patients’ pain and staff were using the fast-track process for early discharge. Patients said staff respected their rights: in particular privacy and dignity. Patients and their relatives told us where there were concerns staff were available for discussions.

Patients at the end of their life were able to make decisions about the medical procedures to be followed in the event of cardiopulmonary arrest. If the decision made was not to attempt to resuscitate the patient, it was recorded and brought to the attention of all medical staff involved in the delivery of care.

Patients were treated with compassion and were not expected to wait for pain medication. Doctors prescribed medicines in advance to prevent delays in administering medicines to patients in pain. Medicines to be taken as required were prescribed to ensure patients were comfortable between other scheduled medicines.

Patients were cared for by staff with an understanding of end of life care. There were nurses on each ward who specialised in specific topics including end of life care. These staff were able to support other staff who needed guidance or advice. Doctors completed mandatory training on end of life care during their teaching.

Outpatients

Good

Updated 14 May 2014

Patients received safe care. Staff were skilled and caring and knew their responsibilities to keep patients safe. Risk assessments had been completed and actions identified to improve the service. The clinic was clean and a refurbishment programme had started. Capacity remained a concern because demand had increased by 10% over the year prior to our inspection. The trust was planning to improve capacity at the Horton by providing two additional clinic rooms in the refurbishment. Audits for the “choose and book” system had taken place and the trust was in the process of re-profiling outpatients to improve the patient experience.

We spoke with ten patients and the majority had no problem getting an appointment and all tests and x-rays had been completed in a timely manner. Eight patients were complimentary about the service and two told us the service was excellent overall. Two patients had problems getting an appointment in a timely manner.

There was a culture between staff to improve the patient experience and be the best they could be. Patient views and experience had been sought to help improve the service. Staff had endeavoured to answer any verbal concerns raised with them immediately.

The trust were keen to develop directly bookable appointments that relieved pressure on staff and the time it took patients to book individual appointments over the phone. The plan was to improve the time automatic letters were sent for appointments and cancellations.