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John Radcliffe Hospital Requires improvement

Details of this locations CQC registration


Here you will find the list of services and areas where we, the Care Quality Commission, authorise and regulate this service to operate. If you think this service is operating services not listed here please contact us

Type of service
  • Community services - Healthcare
  • Hospital
Specialisms/services
  • Services for everyone
Local authority
  • Oxfordshire

Regulated services/activities

CQC register John Radcliffe Hospital to carry out the following legally regulated services here:

Personal care

  • Dr Bruno Holthof is responsible for these services.

Maternity and midwifery services

  • Dr Bruno Holthof is responsible for these services.

Termination of pregnancies

  • Dr Bruno Holthof is responsible for these services.

Nursing care

  • Dr Bruno Holthof is responsible for these services.

Family planning services

  • Dr Bruno Holthof is responsible for these services.

Treatment of disease, disorder or injury

  • Dr Bruno Holthof is responsible for these services.

Assessment or medical treatment for persons detained under the 1983 Act

  • Dr Bruno Holthof is responsible for these services.

Surgical procedures

  • Dr Bruno Holthof is responsible for these services.
Condition of this registration relating to carrying out this regulated activity

During an inspection by the Care Quality Commission on 7 December 2018 we found patients’ privacy was not maintained at all times. This was because we found the windows in the double doors leading directly into theatre one were unobscured. The inspector was able to look directly into the theatre and see the patient undergoing surgery. Any member of staff or patient passing would have direct view of patients in the theatre.

During an inspection by the Care Quality Commission between on 21 November and 7 December 2018 we observed the risk to the health and safety of service users receiving care and treatment and to staff in the main operating department had not be assessed and mitigated.

a) In the corridor around theatre 3 and 4 there was damage to the floor covered by tape, and on visual inspection there was a dent. A staff member had tripped over this area of damaged floor in June 2018 and sustained an injury to their arm. We were told they were off sick for one month as a result of this injury. The incident was reported and the RIDDOR notification made retrospectively, triggered by our request for the report, and the report indicates they were off work for over seven days. No repair or remedial work had been undertaken at the time of the inspections.

b) In the coffee room inside the main operating department there was a hole in the vinyl flooring and lifted edges creating a trip hazard.

c) Due to the

In areas of the main operating department the fabric of the environment was found to be in a poor state of repair and effective cleaning could not be assured, presenting a potential infection control risk. These areas were in patient, staff and clinical areas. Around the entire theatre complex paint was seen to be peeling off walls. Doors and walls were damaged, exposing underlying surfaces and material such as wood and concrete.

a) In theatre 4 anaesthetic room the doors were damaged and unsealed wood exposed.

b) Inside theatre 1 there was reported to be a hole in the floor covered in tape, which had been there for 8 months.

c) Inside theatre 2 there was reported to be a hole in the floor covered in tape, which had been there for 6 months.

d) In anaesthetic room 5 the work surface was chipped revealing unsealed wood underneath.

e) In anaesthetic room 3 the work surface was chipped revealing unsealed wood underneath.

f) In the theatre corridor doors, outside anaesthetic room 8, had b

In areas of the main operating department the fabric of the environment was found to be in a poor state of repair and effective cleaning could not be assured, presenting a potential infection control risk. These areas were in patient, staff and clinical areas. Around the entire theatre complex paint was seen to be peeling off walls. Doors and walls were damaged, exposing underlying surfaces and material such as wood and concrete.

i) Medical equipment (including monitors, scanning units, stacks) was stored in the corridors with no evidence the equipment had been cleaned. There was no assurance that the equipment was cleaned prior to it being wheeled into the theatres. Equipment was not covered. A senior member of staff was unable to assure us that equipment was cleaned before use.

j) Single use sterile sealed equipment was observed stored in boxes on the floor, throughout the operating department. This is considered to be an infection control risk as items should be elevated off the

Diagnostic and screening procedures

  • Dr Bruno Holthof is responsible for these services.