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Inspection Summary


Overall summary & rating

Good

Updated 7 June 2019

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

  • People were protected from harm. Lessons were learned and communicated widely to support improvement in other areas where relevant, as well as services that are directly affected.
  • When people received care from a range of different staff, teams or services, it was co-ordinated. Staff worked collaboratively to understand and meet the range and complexity of people’s needs.
  • People were supported, treated with dignity and respect and were involved as partners in their care
  • Reasonable adjustments were made and action taken to remove barriers when people found it hard to access or use services.
  • Consent to care and treatment was obtained in line with legislation and guidance, including the Mental Capacity act 2005. People were supported to make decisions and, where appropriate, their mental capacity was assessed and recorded.
  • Leaders were visible and approachable. Leaders modelled and encouraged compassionate, inclusive and supportive relationships among staff so that they felt respected, valued and supported.
  • There was an effective and comprehensive process to identify, understand, monitor and address future and current risk.

However,

  • The services provided mandatory training in key skills to all staff but not everyone had completed it. Nursing staff compliance was significantly higher than medical staff.
  • Management and support arrangements for staff were not always effective. Appraisals were significantly below the trust target of 90% for all staff groups with the exception of medical staff.
  • The services did not always have enough nursing staff, with the right mix of qualification and skills, although they were working hard to remedy this.
  • While the trust took complaints seriously and ensured they were investigated the trust’s responses to complaints were not always completed in a timely manner.
  • A proportion of patients did experience a delay when medically fit for discharge or transfer.
  • There was no vision for what the ED at the Horton General Hospital wanted to achieve and no workable plans developed with involvement from staff, patients, and key groups representing the local community.
Inspection areas

Safe

Requires improvement

Updated 7 June 2019

Effective

Good

Updated 7 June 2019

Caring

Good

Updated 7 June 2019

Responsive

Good

Updated 7 June 2019

Well-led

Good

Updated 7 June 2019

Checks on specific services

Medical care (including older people’s care)

Good

Updated 7 June 2019

Our rating of this service stayed the same. We rated it as good because:

  • People were protected from harm. Lessons were learned and communicated widely to support improvement in other areas where relevant, as well as services that are directly affected.
  • When people received care from a range of different staff, teams or services, it was co-ordinated. All relevant teams were involved in assessing, planning and delivering people’s care and treatment. Staff worked collaboratively to understand and meet the range and complexity of people’s needs.
  • People were supported, treated with dignity and respect and were involved as partners in their care. People were treated with dignity, respect and kindness during all interactions with staff and relationships with staff are positive.
  • Reasonable adjustments were made and action taken to remove barriers when people find it hard to access or use services.
  • Consent to care and treatment was obtained in line with legislation and guidance, including the Mental Capacity Act 2005. People were supported to make decisions and, where appropriate, their mental capacity was assessed and recorded.
  • Leaders were visible and approachable. Leaders modelled and encouraged compassionate, inclusive and supportive relationships among staff so that they felt respected, valued and supported.
  • There was an effective and comprehensive process to identify, understand, monitor and address future and current risk.

However,

  • The service provided mandatory training in key skills to all staff but not everyone had completed it. Nursing staff compliance was significantly higher than medical staff.
  • Substances hazardous to health were not always stored safely.
  • There was a gap in the management and support arrangements for staff. Appraisals were significantly below the trust target of 90% for all staff groups with the exception of medical staff. The medicine division had developed actions to address the gap in compliance, and action plans were in place at directorate level.
  • Outcomes for stroke patients had deteriorated from grade C in 2017 to grade D in 2018.
  • The trust’s responses to complaints were not always completed in a timely manner. The trust did not have a target for closing complex complaints, which some of these complaints may have been.
  • A proportion of patients did experience a delay when medically fit with their transfer from hospital.

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.”

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.

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.

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.

Outpatients and diagnostic imaging

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.

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.

Urgent and emergency services

Requires improvement

Updated 7 June 2019

Our rating of this service went down. We rated it as requires improvement because:

  • The service provided mandatory training in key skills to all staff but not everyone had completed it.
  • Staff were not always given the opportunity to have an annual appraisal.
  • The service did not always control infection risk well. Staff did not always keep equipment and the premises clean. Control measures to prevent the spread of infection were not always in use in the ED.
  • Staff did not always adhere to trust medicines management policy.
  • The environment was not always suitable for services provided.
  • Privacy and dignity was compromised for some patients in the ED.
  • The service did not always have enough nursing staff, with the right mix of qualification and skills, although they were working hard to remedy this.
  • There was no vision for what the ED at the Horton General Hospital wanted to achieve and no workable plans developed with involvement from staff, patients, and key groups representing the local community.

However:

  • The service provided care and treatment based on national guidance and monitored evidence of its effectiveness.
  • Leaders on the wards had the skills, knowledge, experience and integrity they needed to fulfil their roles.
  • The service had enough medical staff with the right qualifications, skills, training and experience to keep people safe.
  • The trust had processes to ensure care and treatment was aligned with current evidence-based practice.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • The trust planned and provided services in a way that met the needs of local people and took account of patients’ individual needs.