John Radcliffe Hospital

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment in September 2021, we did not rate this key question. At this assessment, we rated the service good.

Good: This meant people’s outcomes were consistently good, and people’s feedback confirmed this. Although we found some issues with face to face assessments.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

The service did not always make sure people’s care and treatment were effective. There were issues when assessing and reviewing women’s health, care, wellbeing and communication needs with them.

At our last inspection in 2021, we told the service to ensure they assessed women and recorded actions at every appointment. Digital care records had improved documentation and oversight that fed into audits.

The service used two electronic patient record systems, which did not fully integrate. Maternity care records captured holistic assessments and reviews of pregnant women throughout their pregnancy and childbirth journey and captured themes used to audit care and treatment. Key information such as medication, pathology results and safeguarding details recorded on the trust-wide system did not always transfer to the maternity system. This is a nationally recognised risk, as stated in the Ockendon review and subsequent recommendations (2022). However, staff could access both sets of records using protected passcodes.

We reviewed 10 maternity electronic care records. The maternity electronic patient record system was linked to an external application so women could view their records. Four of the records confirmed that, safeguarding and medication information was not readily available on the maternity records but could be viewed on the trust wide patient record but most staff understood they needed to check both systems.

Service data showed that staff did not always complete electronic Venous Thromboembolism (VTE) assessments during pregnancy, childbirth and during the early postnatal period, due to the changes in electronic patient records. Leaders monitored compliance and introduced measures to improve compliance. Data showed improvement was ongoing and required additional monitoring.

However, the maternity care record system supported staff when they completed holistic antenatal booking risk assessments recording psychological, social and medical needs, and placed women on appropriate care pathways. Women found to have complex needs were referred to obstetric teams. Staff referred women with complex mental health needs to perinatal services and escalated safeguarding concerns.

Midwives completed diagnostic tests such as blood sampling and made ultrasound referrals.

Staff developed care plans that met the needs identified during assessment. Care plans were personalised and staff updated care plans at each visit.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards. However, some care pathways were not effective due to capacity and staffing issues within maternity.

Maternity care was aligned to national guidance. Assessments were holistic and provided fetal and maternal medicine clinics for women with comorbidities, complex mental health and fetal deviations from normal. The Silver Star fetal and maternal medicine unit provided specialist care for about 500 pregnant mothers and their babies each year and was supported by the trust’s charity.

Staff followed a standard operating procedure to detect and treat sepsis, and managers monitored the occurrence of sepsis and monitored outcomes and readmission for sepsis.

Managers ensured that staff received the necessary specialist training for their roles. For example, staff working in the observation area attended the ‘in house’ Enhanced Maternity Care study day.

The team included or had access to a range of specialists required to meet the needs of patients in the service. As well as doctors and midwives, women had access to nurses, hearing screening team, physiotherapists, counselling services, social workers, speech and language therapists, and dieticians.

Professional midwifery advocates (PMAs) supported reflection on practice for personal support and professional development. Managers provided appraisal of their staff work performance. Staff told us that they had an appraisal in the last 12 months. Data provided post inspection showed that 91.3% of non-medical and 97.4% of medical staff had an appraisal at the time of the inspection.

Managers ensured that staff had access to regular team meetings and provided remote access for staff wishing to attend from home.

Managers dealt with poor staff performance by speaking to staff face to face, via appraisals and following human resources policies.

However, although guidelines were in date, some lacked clarity. For example, we told leaders the observation area standard operating procedure (SoP) required clarification and strengthening following the inspection. Leaders took prompt action to review and update the SoP.

The service worked well across teams and services to support people most of the time. They shared their assessments of when people moved between different departments or services most of the time.

Safety huddles on delivery suite were multidisciplinary and attendance was recorded. We saw good practice by theatre staff who completed robust handovers and compliance to the management of the World Health Organisations (WHO) surgical checklist procedure reflected national guidelines.

Maternity teams had effective working relationships with other relevant departments, including discharge and specialist teams like safeguarding, physiotherapists and the learning disabilities team.

Staff held regular multidisciplinary meetings for women with comorbidities and complex social and mental health needs. For example, women with diabetes or who developed gestational diabetes were offered glucose testing and monitoring and a diabetes multidisciplinary team provided additional care.

Handovers between teams were well managed and recorded on the patient record.

However, during inspection we found the obstetric reviews were carried out outside delivery rooms, meaning staff did not always have direct sight of patients or access to equipment, and physical examinations were inconsistent. This did not meet national guidance. We raised concerns and managers took immediate action to address this. Consultants reminded obstetric staff to review high-risk patients face-to-face in line with the recommendations of the Ockenden (2022) report which identified the importance of continuous risk assessment in labour.

Staff in the maternity assessment unit completed a standardised risk prioritisation tool and leaders monitored compliance. The service supported people to manage their health and wellbeing, so people could maximise their independence, choice and control. The service had systems to support people to live healthier lives, or where possible, reduce their future needs for care and support.

Staff supported women to live healthier lives. For example, through participation in smoking cessation schemes, healthy eating advice, and screening for various complications of pregnancy and diabetes.

The service offered women who smoked support and financial incentives to quit smoking. Women had to be current smokers, have increased carbon monoxide readings and the desire to quit smoking since conception.

Staff received UNICEF ‘Baby Friendly’ Infant feeding training by the infant feeding specialist and facilitated daily infant feeding support sessions for positioning and attachment on the postnatal ward. Also, staff ran 2 infant feeding outpatient clinics for women with complex feeding issues.

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

Maternity data including the maternity exception report and incident data showed shortfalls, including lengthy delays in women’s access to the maternity assessment unit, medical reviews, induction of labour, and readmission rates.

The service did not provide annual data for maternity assessment and triage wait times. However, data for the maternity assessment unit for September 2025 showed 583 attendances and that only 36.8% of women were seen by a midwife within 15 minutes.

Staff on day assessment unit highlighted issues with medical reviews in the afternoons although the data for September did show that 55.5% of women rated as moderate risk in the day assessment were seen within one hour.

We found inconsistency in the reporting of delays in induction, the trust incident data for the period November 24 to November 25 showed 32 delays over 24 hours. However, the trust’s NICE Red Flag data dated April to October 2025 showed 206 instances. The trust advised that this is because the incident data delays do not always meet the incident threshold. However, NHS guidance states the staff should report ‘any unintended or unexpected incidents which could have, or did, lead to harm for one or more patient’s receiving healthcare.

Leaders conducted an audit of timing of category 1 and category 2 caesarean sections in July 2025. Data confirmed that 93% of category 1 (meaning high risk) met the 30-minute target. Category 2 caesarean’s (meaning moderate risk) showed 64% met the 75-minute standard. Delays were mostly due to capacity on the unit. The service identified the following risks: inaccurate timing data on the electronic patient record, incomplete documentation about the caesarean decision and delays in category 2 caesarean. An action plan was implemented and due to be signed off during the report writing process.

The trust monitored patient feedback using the friends and family test which was available on the women’s digital patient application. Women and families recorded feedback on an electronic feedback Padlet in most areas of the service. The service reported patient experience to identify themes to help inform improvement. The Triangulation and Learning Committee (TALC) met with the maternity voices to receive the quarterly survey feedback. The service acted on feedback and introduced 24-hour partner visiting to support women’s emotional wellbeing and bonding in the early postnatal period.

Staff raised concerns about limited breastfeeding support. Midwives told us there was a shortage of breastfeeding equipment and delays in accessing the tongue-tie service, which could contribute to feeding difficulties. We observed women struggling to breastfeed in the observation area. Poor feeding can lead to babies being readmitted to hospital, and the trust’s neonatal readmission rates were higher than national averages.

Staff raised concerns about the quality and availability of breast pumps, reporting frequent complaints from mothers trying to initiate breastfeeding. Managers submitted a business case for 15 additional pumps. However, leaders could only fund five new breast pumps to help mothers initiate the production of breastmilk. National data shows that the trust was in the upper 25% for babies readmitted within 30 days, many on day six due to weight loss, indicating gaps in the early identification and management of feeding problems.

However, the service monitored performance using key performance indicators aligned to national and local benchmarks. Leaders used the Maternity Performance Dashboard to track key indicators, red flags, and staffing data, with ethnicity monitoring to identify trends.

Staff took part in a structured audit programme, including national maternity and neonatal audits, with clear leads and completion dates. The service used the National Perinatal Mortality Review Tool (PMRT) to review perinatal deaths and report findings to the trust board.

Leaders demonstrated compliance with the Maternity Incentive Scheme year 6 safety actions and were on track for year 7. They also collected Clinical Quality Improvement Metrics (CQIM) and submitted required data to the Maternity Services Data Set.

Monthly 'Maternity Services Quality Reports' provided oversight of activity, safety, incidents and training. Staff used recognised assessment tools to monitor outcomes and respond to clinical deterioration, supporting continuous quality improvement and better patient outcomes.

Staff used portable equipment to support patients effectively for example, for prompt access to blood test and scan results. Staff on the delivery suite accessed a blood gas machine which provided valuable information about the condition of a baby soon after delivery. Doctors had access to portable ultrasound and bladder scanners within the unit.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff took all practical steps to enable women and their families to make their own decisions regarding their care pathways.

Staff gained consent for care and treatment and recorded this on the patient record.

Staff assessed and recorded mental capacity to consent appropriately and made referrals, such as to learning disability teams, when they had concerns. Assessments were decision-specific for significant decisions.

When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture, and history.