The John Radcliffe Hospital, Oxford is the largest hospital in the Oxford University Hospitals NHS Trust, with 832 beds, and serves a population of around 655,000 people. It provides acute medical and surgical services, trauma, and intensive care and offers specialist and general clinical services to the people of Oxfordshire. The John Radcliffe Hospital site includes the Children's Hospital, Oxford Eye Hospital, Oxford Heart Centre, Women's Centre, Neurosciences Centre, Medical Emergency Unit, Surgical Emergency Unit, and West Wing. It is Oxfordshire's main accident and emergency (A&E) site. The trust provides 90 specialist services and is the lead hospital in regional networks for trauma; vascular surgery; neonatal intensive care; primary coronary intervention and stroke. It also works in collaborative networks with Stoke Mandeville, for specialist burns services and with Southampton for paediatric specialist services in cardiac care, neurosurgery, and critical care retrieval.
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
- Family planning
- Maternity and midwifery services
- Nursing care
- Personal care
- Surgical procedures
- Termination of pregnancies
- Treatment of disease, disorder or injury
Many of the services provided by the John Radcliffe hospital were delivered to a good standard, but overall the hospital required improvement. The hospital was failing to plan and deliver care to patients needing A&E, surgical and outpatient care and to meet their needs and ensure their welfare and safety. Patient records were not being completed in some areas of the hospital.
Shortages of staff within the maternity department, on surgical wards and in operating theatres meant that staff were not able to provide the best care at all times. There were not sufficient numbers of qualified, skilled, or experienced staff to meet patients’ needs at all times. The trust delivers a number of induction programmes for new staff. However, some staff we spoke with did not always feel appropriately inducted or supported.
Although in many areas of the trust there were sufficient staff to meet people’s needs this was not the case in the maternity department, surgical wards and operating theatres.
The trust told us that they had difficulties recruiting staff because of the high cost of living within Oxford and because of the difficulties and cost of parking on the hospital site. The trust told us there had been a recruitment drive and a recent cohort of registered nurses from Spain had recently started work. Recruitment was ongoing and further recruitment drives in Scotland and Wales were planned.
There were nursing and healthcare assistant staff shortages reported on surgical wards and in theatres. In December 2013 the vacancy rate for nursing staff was 16.4% in the neurosciences, orthopaedics, and trauma and specialist surgery division. We saw evidence of patients who were fit to be transferred from the intensive care unit onto a surgery ward, but because of staff shortages, there were no beds available in the surgical wards. This put pressure on staff to discharge patients to create capacity.
In theatres the vacancy rate for nursing and medical staff was 19% in January 2014. There was regular use of temporary (bank and agency) staff. Staff told us they worked long days or did overtime on the bank. However, many staff were fatigued and were volunteering less. Staff reported high levels of stress and low morale due to workload.
We were told that operating lists were cancelled about once a week due to staff shortage. Theatre staff told us that sometimes theatres had only two theatre staff supporting the surgeon and anaesthetist. The Association for Perioperative Practice (AfPP) recommends that there should be three staff (three nurses or two nurses and one operating department practitioners (ODPs). Staff in the main theatres told us that they regularly had only two staff. They said this occurred approximately once a week. They said this had the potential to be unsafe.
In neurosurgery junior doctors told us that sometimes the medical staffing levels felt unsafe. Out of hours there was one junior doctor (Senior House Officer) looking after 74 inpatients, while a registrar provided emergency cover. There was no phlebotomy service, which added further to their workload. We saw this in practice during our unannounced visit.
In maternity services the delivery suite had been without a manager for 18 months. Elements of the role were being covered by three band 7 midwives over three days a week. The trust had attempted to recruit to this role. Although the delivery suite provided women in labour with one to one care, staffing levels were not always sufficient to ensure women received the care and support they needed. Where recruitment to new posts occurred this was of newly qualified midwives who needed support from the experienced midwives within the department. This added further pressure to those staff. In addition, newly qualified midwives reported not receiving adequate preceptorship. The number of supervisors of midwives was below that recommended in national guidance from the Nursing and Midwifery Council. There was not sufficient consultant presence within the delivery suite to meet national standards, although midwifery staff reported that consultants were supportive.
Staffing levels had been recently increased on medical wards due to audit and assessment of patients’ needs. We were told that this had improved morale on the wards.
Cleanliness and infection control
Within the hospital there were suitable infection control procedures and practices. Hand-washing facilities were clearly indicated in departments and hand sanitising gel was placed appropriately. Staff said they had enough personal protective equipment including gloves and aprons. In most areas nursing staff were wearing standard uniforms and all staff we saw were adhering to infection control protocols (such as being “bare below the elbow”, without nail varnish, and wearing minimal jewellery).
Infection control procedures, for example, hand hygiene and cleaning audits, were undertaken monthly and the results displayed in specific areas of hospital. The hospital was clean. We saw staff washing their hands and wearing aprons and gloves. On the adult intensive care unit hand hygiene was assessed at only 87% completed and cleaning at only 83%. The matron advised that ongoing works takes place to review all areas audited. We observed good hand hygiene taking place in all areas. However, we noted that staff in intensive care did not adhere strictly to the uniform policy with hair touching collars and earrings which was not in line with the trust policy.
The level of hospital acquired infections was monitored within the hospital. Reported Clostridium Difficile and methicillin resistant Staphylococcus Aureus (MRSA) bacteraemia were within expected limits. Each reported case underwent an in-depth review, and were discussed at the infection control committee. We saw good practice in the children’s A&E department where a child with chicken pox was cared for in a cubicle.