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John Radcliffe Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 7 June 2019

Our rating of services stayed the same. We rated it them as requires improvement because:

  • Most services had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. However, some risks which had a potential to have a high impact, were not considered as a risk and therefore were not captured on the services risk register.
  • The services provided mandatory training in key skills to all staff but not everyone had completed their training. Nursing staff compliance was significantly higher than medical staff.

  • There was a gap in the management and support arrangements for staff. Appraisals were significantly below the trust target of 90% for staff groups except medical staff.
  • The trust had a recruitment program and was undertaking various initiative to encourage staff to stay. However, some services, such as surgery, gynaecology and midwifery did not always have enough nursing or midwifery staff, with the right mix of qualification and skills.

  • Patients care records were not always stored in a way which protected patient confidentiality.
  • Medicines were not always safely stored and managed at all times.
  • Some services 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 main theatres.
  • The environment was not always suitable for services provided. Areas in some of the main operating department and wards were damaged and in need of repair and posed potential risks to patient and staff safety.
  • Privacy and dignity was compromised for some patients in the main operating department.
  • National standards for care and treatment in some key areas were not always met. Referral to treatment (percentage within 18 weeks) and average length of stay for elective patients did not always meet the England average. The percentage of cancelled operations was higher than the England average.
  • The trust’s responses to complaints were not always completed in a timely manner.
  • A proportion of patients experience a delay when medically fit for discharge.
  • 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.

However

  • The services managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learnt. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • In general services provided care and treatment based on national guidance and monitored evidence of its effectiveness. Although we found the maternity service had not reviewed or updated some of the protocols and guidelines against best practice and national guidance.
  • There was good multidisciplinary working. When people received care from a range staff, teams or services, it was co-ordinated.
  • People were supported, treated with dignity and respect and were involved as partners in their care. People were treated with kindness during all interactions with staff and relationships with staff were positive.
  • 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.
  • Most leaders were visible and approachable. Leaders modelled and encouraged compassionate, inclusive and supportive relationships among staff so that they felt respected, valued and supported.
Inspection areas

Safe

Requires improvement

Updated 7 June 2019

Effective

Good

Updated 7 June 2019

Caring

Good

Updated 7 June 2019

Responsive

Requires improvement

Updated 7 June 2019

Well-led

Requires improvement

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:

  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • When people received care from a range of different staff, teams or services, it was co-ordinated. All relevant staff, teams 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 kindness during all interactions with staff and relationships with staff were positive.
  • 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 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.
  • There was a gap in the management and support arrangements for staff. Appraisals were significantly below the trust target of 90% for staff groups except medical staff. The medicine division had developed actions to address the gap in compliance, and action plans were in place at directorate level.

  • 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.
  • Processes to ensure patients were kept safe were not always reliable. Patients’ records were not always fully completed, and medicines storage did not always comply with guidance.

Services for children & young people

Good

Updated 14 May 2014

We visited all the wards in the children hospital including the paediatric intensive care unit (PICU), the paediatric high dependency unit (PHDU) and the neonatal intensive care unit (NICU). We spoke to 45 members of staff. This included health care assistants (HCAs), student nurses, staff nurses, midwives, senior nursing staff, doctors, registrars, consultant, and anaesthetists, operating department practitioners, nurse practitioners, administration staff, physiotherapists, and play specialists. We also spoke to 14 parents and relatives, three children and two young people.

Parents, children, and young people were positive about the care and support their received. They told us they were kept informed and involved in making decisions. Staffing levels were considered when managing the number of beds available to be used. The trust was aware of areas were additional staff were required and they were actively recruiting to these areas. Staff told us they felt supported and the children’s hospital was a good place to work. There were systems in place to ensure children at risk of harm or considered to be of concerns were identified and protected if seen in the hospital. Staff were aware of how to report incidents and this information was monitored, reviewed and learning shared with the staff. There was an established governance system in place that included monitoring complaints, incidents, outcomes from audits and the adherence to national guidelines. Young people’s opinions and input was actively sought through the Young People's Executive. 

Critical care

Good

Updated 14 May 2014

Patients received safe and effective care. While staff recruitment and retention was recognised by the senior staff as an issue, the levels and skills of staff on a day-to-day basis were consistently managed. Clinical outcomes were monitored and demonstrated good outcomes for patients.

Patients and relatives told us the caring, consideration and compassion of staff was of a very high level. Considerable work had recently been undertaken to improve the responsiveness of the service to ensure patients were discharged when they were ready and delays were minimised. This also improved the responsiveness for pre-planned admissions following surgery to take place. The departments were well led and demonstrated a positive leadership and culture. A business case had been submitted to the trust board for future improvements for an increase in high dependency beds to meet the identified demand as the service sometimes runs at over 100% capacity.

End of life care

Good

Updated 14 May 2014

Patients received safe and effective end of life care based on evidence based guidelines, national standards, and protocols. Staff were caring and motivated. They demonstrated commitment to meeting patients’ end of life needs and to supporting patients’ relatives at this time.

A specialist palliative care team was based in the hospital and provided advice, training and support to hospital staff Monday to Friday. 24-hour, specialist advice was provided by staff at Michael Sobell House hospice, based at the Trust’s Churchill Hospital. The hospital palliative care team were part of a wider specialist team who worked collaboratively across the Trust’s four hospital sites and in the local community. A member of the team was the National Director for End of Life Care and chair of the Leadership Alliance for the Care of Dying People.

Feedback from patients receiving end of life care, and their relatives, was positive. They were well informed, had been asked what was important to them, and were involved in decision-making. They told us that staff were sensitive to their needs and treated them as a whole person.

Outpatients and diagnostic imaging

Good

Updated 14 May 2014

Patients received safe care because risks to patients were understood and were being managed. Hospital policies were based on national standards and evidence-based guidelines and adherence with these was monitored. An uncommissioned 10% rise in demand for outpatient appointments over the past year meant the Trust struggled to meet national standards for referral to treatment time (RTT) for patients. The trust agreed to fail RTT targets for January, February, and March 2014 with the NHS Trust Development Authority, who provide oversight and governance for all NHS trusts, to enable patients who had been waiting longest to be prioritised. This meant that patient safety was prioritised over meeting targets.

Patients were unable to book into appointments using the Choose and Book system on 50% of attempts as this could not be done online and there were not enough administrative staff available to answer calls and make bookings. This resulted in poor experiences for some patients when trying to book appointments, to make queries or change appointments. The way clinics were set up in booking systems did not make the best use of clinic facilities available, which meant that patients sometimes faced unnecessarily long waits to be seen in clinic. In order to address capacity issues, a trust-wide project was in progress to increase the number of appointments available and to ensure that clinic facilities were used more efficiently. This project was on schedule and was due to be rolled out to clinics in May/June 2014.

Clinics and waiting areas were clean and well-maintained but space was limited, which meant waiting areas were often overcrowded. Initiatives were in place to improve the experience for patients and keep them informed of waiting times but these were not used consistently in all clinics.

Despite administrative challenges, patients were highly complimentary about the clinical care they received. Staff were appropriately trained, motivated, and worked well together to ensure that outcomes for patients were good. 

Surgery

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.
  • 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 main theatres.
  • The environment was not always suitable for services provided. Areas in some of the theatres and wards were damaged and in need of repair and posed potential risks to patient and staff safety. Staff in the main theatre department had become disheartened that the refurbishment had not happened and had accepted the environment they worked in was substandard. Risks were not adequately reflected on the risk registers.
  • Privacy and dignity was compromised for some patients in the main theatres.
  • 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.
  • The security of record keeping was not consistent across the wards.
  • National standards for care and treatment in some key areas were not always met. Referral to treatment (percentage within 18 weeks) and average length of stay for elective patients did not always meet the England average. The percentage of cancelled operations was higher than the England average.
  • Signage for surgical wards at the John Radcliffe Hospitals was confusing and not clear enough to be understood by people who were unfamiliar with the environment.
  • 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.
  • We could see how nurse led roles, rota changes, and adaptations and recruitment were planned and discussed to combat nurse staffing shortfalls.
  • 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.

Urgent and emergency services

Requires improvement

Updated 7 June 2019

Our rating of this service stayed the same. 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.
  • Staff did not always adhere to trust medicines management policy.
  • 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.
  • 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.
  • The security of patient health records was not maintained in the EAU.
  • Signage for the ED and ED reception area at the John Radcliffe Hospitals was confusing and not clear enough to be understood by people who were unfamiliar with the environment.

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.

Gynaecology

Requires improvement

Updated 7 June 2019

This was the first inspection of the core service of gynaecology and termination of pregnancy as a separate service therefore we cannot compare our new ratings directly with previous maternity and gynaecology ratings.

We rated it as requires improvement because:

  • Recent organisation changes meant there were new leaders at directorate and divisional levels. 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 risks 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.
  • People could not always access services within the national guidelines identified timescales.
  • 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.
  • Infection prevention and control processes were not always practiced and completed in accordance with local and national policy.
  • Patients care records were not always stored in a way which protected patient confidentiality.
  • Medicines were not always stored in line with best practice.

However,

  • Incident reporting systems were in place and there was a culture of reporting, investigating and learning from incidents.
  • There were effective arrangements in place to safeguard patients from abuse and mitigate the risk of it happening.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Emotional support was provided by people with appropriate skills and experience.
  • Feedback from patients about their experience of care was consistently positive. Patients were treated with respect and dignity.
  • The service recognised the differing needs of patients and delivered care which met these.
  • There was a clear statement of vision and values which was understood by staff at all levels.
  • Staff praised local, divisional and directorate management for their leadership skills

Maternity

Good

Updated 7 June 2019

This was the first inspection of the core service of maternity as a separate service therefore we cannot compare our new ratings directly with previous maternity and gynaecology ratings.

We rated it as good because:

  • Staff demonstrated care and compassion when caring for women.
  • Staff were clear about their safeguarding responsibilities and if there was a concern about a woman’s wellbeing staff understood and followed safeguarding procedures. Staff completed, assessed, monitored and managed risks appropriately. However safeguarding training targets were not met by the medical staff.
  • Women had access to 24/7 telephone guidance and prompt responses. The trust provided maternity services seven days a week. There was good multidisciplinary working evident across the maternity unit.
  • The service provided care and treatment that was based on national guidance and evidenced its effectiveness.
  • There was openness and transparency about safety, and continual learning was encouraged. Staff were supported to report incidents, including near misses. All units were secured both day and night.
  • Services were planned and delivered to meet the needs of the local population and reflected some aspects of the National Maternity Review.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Managers at local levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care.
  • There was a clear statement of vision and values which was understood by staff at all levels.

However:

  • There was an improvement from the 2017 inspection in the way the service controlled infection but we saw areas where infection control was not always effective.
  • The service did not always store medicines safely. Medicines were stored in areas that were too warm but no actions had been taken. Some medicines were stored in unlocked fridges.
  • The service did not have an effective system in place to ensure all staff completed their mandatory training. Neither the midwifery or medical staff achieved the trusts 90% completion target in all the mandatory training subjects.
  • There was not enough midwifery staffing to reach the RCOG recommended midwife ratio of 1:28. Although the service had an ongoing recruitment programme the service was struggling to recruit sufficient midwives.
  • Women could not always give birth in the place of their choosing due to midwifery shortages.
  • The service had not reviewed or updated some of the protocols and guidelines against best practice and national guidance.
  • The service did not always investigate complaints in a timely manner or in line with their complaints policy.
  • Not all staff had received yearly appraisals to provide support and monitor the effectiveness of the service.
  • There appeared to be a lack of support for the local managers and staff from divisional and executive level.

Maternity (inpatient services)

Updated 27 March 2018

We have not given this service an overall rating as we did not complete a full inspection of the service.

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. However, not all staff had completed safeguarding children’s training to the expected level.

  • The service did not manage the control of the risk of infection consistently. Staff did not ensure ward areas and equipment were kept clean to prevent the spread of infection. Staff did not always follow good infection control practices.

  • Medicines were not always stored securely and some staff did not follow the trust’s medicines management policy when administering medicines.

  • Areas of the building were in need of repair and the access to some equipment was compromised with storage areas being cluttered.

  • In order to maintain safe staffing levels the trust relied on staff working flexibly and moving between wards and the delivery suite. They also relied on on-call staff attending the delivery suite out of hours.

  • Systems to monitor the quality of the service to ensure risks were managed were not robust.

  • Although morale was generally good and there were areas where there was a good working relationship between midwifery and medical staff such as the midwifery assessment unit, multi-disciplinary working was not always effective.

However

  • The service provided mandatory training in relevant key skills to all staff and made sure everyone completed it.

  • Staff completed and updated risk assessments for each patient, which informed individual plans of care. They kept clear records and asked for support when necessary.

  • Staff were positive about the support they received from their managers.

  • There was a local vision to reconfigure the foot print for the delivery of the maternity service, with the aim of segregating ante-natal and post-natal patients. This in turn would enable a review of the allocation staffing and skill mix to meet the needs of the patients.

  • The maternity service had links with local academic organisations and collaborated to provide accredited courses which provided development opportunities for staff at many levels.

  • Appropriate governance committees and meetings were in place, which provided a structure to the processes for providing assurance to the board.