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John Radcliffe Hospital Requires improvement

Reports


Inspection carried out on 7 and 8 November 2017

During an inspection to make sure that the improvements required had been made

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.

We carried out a focused unannounced inspection on 7 and 8 November 2017. We inspected the maternity services reviewing the safe and well led domains. This inspection was in response to concerns about the effectiveness of the governance processes and the management of risk.

We have not amended the overall rating of this location as we only inspected  the maternity service provided.

Our key findings were as follows:

  • 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. Neither did staff always follow good infection control practices.

  • Medicines were not always stored securely and some staff did not follow the trust 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 moral 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 antennal and post-natal patients. This in turn would enable a review of the allocation of 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.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must ensure:

  • That there is senior oversight of infection prevention and control (IPC) measures and an IPC strategy and framework for the service is written and shared with staff. .

  • Clinical staff wear appropriate protective wear when undertaking tasks that have potential to spread infection.

  • There are effective procedures in place for clinical waste management and management of sharps boxes.

  • Ensure the fabric of the building particularly plastered walls, are sealed in clinical areas to reduce the risk of cross infection.

  • Steps are taken to ensure medical staff vacancies are recruited to, monitor the effectiveness of this action, and ensure the ward staff are sufficiently supported by the medical staff.

  • Learning from incidents is shared in an effective way with all staff.

  • Review the effectiveness of the quality monitoring of the service to ensure potential risks are identified and action taken to mitigate in a timely way.

  • Medicines are managed and administered in line with the trust’s medicines management policy.

Action a trust SHOULD take is to comply with a minor breach that did not justify regulatory action, to prevent it failing to comply with legal requirements in future, or to improve services.

In addition the trust should ensure:

  • All staff attend safeguarding children training and all midwifery and medical are trained to level 3.

  • Review staffing levels and skill mix across the service to ensure on call staff are not routinely called in at night and to reduce the need to close the Spire MLU due to inadequate staffing levels.

 Professor Edward Baker

Chief Inspector of Hospitals

Inspection carried out on 11 and 12 October 2016

During an inspection to make sure that the improvements required had been made

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.

We carried out a focused unannounced inspection on 11 and 12 October 2016. We inspected the surgical service and the emergency department at this location. As part of this inspection, we returned to see if improvements were made to any concerns identified in February 2014 and March 2014 relevant to the service types inspected.

We rated the surgery service as good and urgent & emergency services as requires improvement.

  • The emergency department had a consistently poorer median time to initial assessment for both adults and children than the England average. Patients arriving via ambulance did not consistently receive an assessment within 15 minutes of arrival. This in turn could impact on the timeliness of screening and the introduction of the sepsis pathway. The department performed significantly worse than the England average on the A&E four hour waiting time target, although the percentage of patients waiting four to 12 hours from decision to admit to admission was better than the national average.
  • The space and layout of the main operating department and the emergency department impacted on the efficiency and flow of patients through the departments.
  • Not all patients who were at risk of developing pressure ulcers in the emergency department were nursed on appropriate pressure relieving mattresses according to their assessed needs.

  • Emergency equipment was available and in the majority was checked daily. The exception was the resuscitation trolley located in the cardiothoracic theatres, which had not been checked since mid-September 2016 (almost one month) and had been covered with other items of equipment.
  • Staff completion of statutory and mandatory training was variable and not in line with the trust’s target in some areas. This included resuscitation training, Mental Capacity Act training and conflict management practical training.
  • All clinical areas were visibly clean, and we observed staff following good infection prevention and control practices to minimise the risk and spread of infection to patients.
  • Staff were aware of their responsibilities and the processes to follow to protect vulnerable adults and children. However, not all staff were up to date with the required level of safeguarding training.
  • Staff were confident with reporting incidents and obtained feedback. There was an emphasis on learning from incidents within departments and across the organisation. Staff were aware of the duty of candour requirements and how it applied to their practice.
  • Overall, staffing levels met the planned levels. The trust achieved this using bank and agency staff for some shifts. Managers followed the trust escalation procedures when they identified staffing shortages for their department. At the time of the inspection the trust had not completed their formal review of acuity and establishment in the ED. Over a four month period, July to October 2016 over half the shifts were staffed at minimum nurse staffing levels.
  • Trust wide medicines management policy and standard operating procedures were in place and monitored through audit. Medicines were stored securely in line with the trust medicines management policy. New staff were supported through a planned induction process. Training opportunities were available although staff reported the main the challenge was having time to attend training.
  • Compliance with appraisal rates for medical staff was in line with the trust’s target; however appraisal rates for nursing staff varied, with some low rates including 43% on the cardiothoracic ward, 61% in ED and 46% in EAU.
  • Staff understood their roles and responsibilities regarding the Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS). However, on one ward, two patients with dementia did not have documented capacity assessments completed.
  • Medical, nursing staff and support workers worked well together as a team. There was respect between a range of specialities and disciplines.However, in the ED multidisciplinary working was variable, junior medical staff found some resistance in patient transfer to the surgical emergency unit and referrals to nursing staff were impeded.
  • Inpatients had plenty of a menu options and meals were said to be of sufficient portion size. Patients in the majors area of ED were offered food and drinks, however, not on a formalised basis.
  • Staff assessed and managed patients' pain levels. However, in the ED not all patients had their pain managed in a timely manner.
  • Care and treatment was planned and delivered in line with current evidence based guidance, standards and best practice. There was good monitoring of compliance with these standards at departmental and division level.
  • In all areas, patients and relatives were positive about the caring attitude of staff, their kindness and their compassion. However, in the ED we observed occasions when patient privacy and confidentiality was not maintained.
  • On the surgical wards staff took time to ensure patients, and their relatives, understood their care and treatment. Patients felt involved in their care and understood their treatment plans. Relatives in the ED did not always feel informed.
  • Staff we spoke with valued and respected the needs of patients and their families. Patients’ emotional, social and religious needs were considered and were reflected in how their care was delivered. However in the ED patients’ holistic needs were not always considered. For example, patients we spoke with said they were cold or relatives had covered the patient. The ED performed significantly worse than the national average for the percentage of patients with a total time within ED of four hours.
  • Patients with mental health conditions were cared for in an environment, which was not secure and had led to absconsion from the emergency department. Although the mental health assessment room in the EAU provided a safe and suitable environment to assess patients.
  • Complaints were investigated thoroughly to improve the quality of care.
  • Patients had timely access to emergency surgical treatment and the trust was taking action to minimise the waiting time for elective surgery. The trust was pro-actively managing capacity for surgical patients.
  • Staff took account of the needs of different people, including those with complex needs when planning and delivering services. Staff showed good understanding and made reasonable adjustments to meet patients’ individual needs.
  • There was an open culture within the hospital. Staff felt the leadership of the trust and within the division, directorates and at local level were visible and supportive.
  • There was a governance structure to monitor the quality, risk and performance of services, which linked in with the trust’s overall governance structure. However, in the ED improvements to the service with regards to service performance and patient flow through the department had not been addressed.
  • The trust core values, which underpinned the trust wide vision, were embedded across the services inspected. These were further supported by the strategic objectives which were reflected in local business plans.

We saw several areas of outstanding practice including:

  • Ward staff and clinical development nurses had developed safety cards. Each nurse had a pack of cards with key safety and organisation information to fit in their pocket. An example of information was where to locate pressure relieving mattresses. Clinical staff told us they were a useful reminder and were well received.

  • The trust had employed a falls safe training lead and falls had reduced from three serious patient falls a month to zero falls.

  • The trust held a weekly serious incident requiring (SIRI) investigation forum open to all staff to discuss learning from incidents and duty of candour requirements.

  • The trust had introduced a peer review programme to engage staff, encourage improvement and share learning across the different divisions.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Improve mandatory training levels for medical and nursing staff.

  • Improve safeguarding children level 3 training for medical and nursing staff

  • Improve the appraisal rates for nursing staff.

  • The trust must ensure that patients receive an initial assessment by an appropriately qualified member of ED staff within 15 minutes of arrival in the ED.

  • The flow of patients through the hospital must be improved to enable the emergency department to meet waiting time targets and enable patients to have timely access to specialist care and treatment.

  • Provide an appropriate and safe environment for the care and treatment of detained patients.

  • Review the use of both paper and electronic records in ED to ensure contemporaneous notes are maintained at all times.

In addition the trust should:

  • Ensure all emergency resuscitation equipment is checked daily.

  • Consider the theatre business plan to agree a way forward to address the constrained theatre environment.

  • Improve patient’s privacy and dignity in the theatre direct admissions (TDA) area in the main operating department.

  • Ensure administrative and clerical staff receive training in how to identify and report abuse in adults.

  • Ensure patients who at risk of developing pressure ulcers in the emergency department are cared for on appropriate pressure relieving mattresses according to their assessed needs.

  • Continue to find solutions to ensure all clinical staff attend compulsory cardiac advance life support training.
  • Ensure staff consistently follow and record the sepsis pathway.
  • Consider ways to improve the arrangements for the safe care of patients at risk of absconding.
  • Ensure patients' pain in ED is appropriately managed in a timely manner.
  • Improve multidisciplinary working between ED, specialist services and teams to facilitate patient flow through the department.
  • Consider the timeline of plans to expand the resuscitation area to determine if these could be brought forward.
  • Improve the arrangements for preserving patients’ privacy and confidentiality in the children’s ED.
  • Ensure patients within the ED are offered food and drinks where clinically safe and appropriate.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 25-26 Feb and 2-3 March 2014

During a routine inspection

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.

Staffing

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.

Inspection carried out on 26, 27 February 2013

During a routine inspection

At this inspection we reviewed the care and treatment provided from one surgical and one medical ward in the main hospital block and inspected the Women’s Centre. We spoke with 29 inpatients, five relatives and 38 staff, including doctors, nurses, midwives and managers. We also observed the care provided to other patients throughout the two days of our inspection.

Patients were complimentary about the care they received. Patients said “The nurses here are brilliant and the cleaners are all very friendly “; “The doctors are very good here” and “Absolutely wonderful midwives and anaesthetists”. We were also told “There is a culture of politeness and making sure everyone is looked after here”.

In all areas inspected, patients told us the environment was very clean. One patient said “The cleanliness is excellent” and another person said “It’s all neat and hygienic. I see all the staff wash their hands and use hand gel before they examine me”.

The majority of patients thought there were enough staff to meet their needs. We were told “Yes, there are enough staff on duty but occasionally they’re extremely busy” and “I would say there are enough staff, I’ve never had to wait for the bell to be answered“.

We found staff received relevant training and professional development to enable them to provide safe care to an appropriate standard. The trust selected new staff using value based interview criteria, such as testing for compassion.

Inspection carried out on 22 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 29 December 2011

During an inspection to make sure that the improvements required had been made

Patients we spoke with said that they had plenty of choice of food and that the portion sizes were good. Most said that the quality of the food was good. Some patients we spoke with said they hadn’t been specifically asked about their dietary requirements. Patients told us that they had not been interrupted during mealtimes.

Inspection carried out on 12 July 2011

During an inspection to make sure that the improvements required had been made

During our visit on 12 July 2011, most patients we spoke to were happy with the level of care they received and the responsiveness of staff. Patients and their relatives said that communication had been good and that they were involved in decision making processes. Staff were observed sitting with patients and taking time to talk with them. When call bells were rung, staff answered promptly. A few patients we spoke to raised concerns about the care they received and communication with staff.

Inspection carried out on 16, 17 May 2011

During a themed inspection looking at Dignity and Nutrition

Patients we spoke to at the John Radcliffe Hospital were complimentary about the staff. Comments included “excellent, couldn’t be better”, “if they can’t do something right away, they will always come back” and “this place is second to none”.

Patients felt that their privacy was respected and the process of care had been explained to them. Some patients commented that staff sometimes provided care without asking them if it was acceptable first.

Information provision was variable. On one ward patients were given leaflets about the hospital while one another, patients commented that they hadn’t received any information but had ‘worked it out with their relatives’. Some patients on the stroke ward outlined that they had not had a chance to adequately discuss their treatment with clinical staff.

Patients stated that there was enough choice on the menu. Views of the quality of the food were mixed. On one ward we visited patients were generally satisfied with the food. However, on another ward, patients commented that the food was ‘terrible’ and ‘awful’. Patients commented that they received the support they required to eat and drink.

Inspection carried out on 14 September and 24 December 2010

During a routine inspection

During our visit on 14 September 2010, we interviewed 14 patients at the John Radcliffe Hospital. Patients, on the whole, were very positive about their experiences of care and treatment. Many patients stated that the medical and nursing staff were excellent and that they “couldn’t do enough for them”. Most patients stated that they were kept informed and were involved in making decisions about treatment options. They stated that they were given enough information both written and verbal to enable this process. Most patients also stated that they felt they were treated with dignity and respect.

The trust also asks patients for their views and experiences of care on a regular basis, and the Commission reviewed these surveys.

The majority of these comments reflected well on the trust, although there were some recurring themes around dissatisfaction with long waiting times for screening and diagnostic procedures, and concerns about the attitudes and care delivered by staff in some instances.

The John Radcliffe Hospital has also been the subject of some significant complaints, one upheld by the Health Service Ombudsman, about not involving patients or their families in making serious decisions about their care.

In summary, while many patients have provided positive feedback, further work is required by the trust to ensure that patient experience of their care is of a consistently high standard.