John Radcliffe Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm. This is the first inspection of the neonatal service. This key question has been rated good.

We have not awarded this service a score for Safe.

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

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Twice daily ward rounds and additional twice daily safety huddles are held Monday to Sunday, including neonatal discussions. Incidents were reviewed regularly, and attendance was extended to all members of the multidisciplinary team, when issues related to perinatal care were discussed.

A monthly quality and safety report provided oversight of incidents, themes, and service changes. This was shared widely with staff via email, the intranet, and paper copies in staff areas to ensure accessibility.

Staff advised us that the learning culture at the trust had improved, the service was working closely with maternity services and was using incidents as an opportunity to improve care, rather than assign blame. The service had seen an increase in the number of near misses and no harm incidents being reported. This demonstrated staff improved awareness of incidents, as an increase in reporting of near miss and no harm incidents indicates a mature, transparent safety culture where staff feel psychologically safe to speak up. Learning from incidents led to improvements. For example, although staff were using sterile techniques when changing fluids, a lack of sufficient sharps bins meant syringes could not always be disposed of immediately. Previously, bins were limited (one per four beds) and stored in cupboards. This was addressed by increasing availability and relocating bins onto mobile trolleys for easier access. Visual prompts were also introduced to highlight bin locations. These incidents were assessed as low harm but still informed meaningful change.

Communication of learning was strengthened through regular updates. The “Big Four” safety messages were revised to a more focused “Top 3” approach to improve staff engagement and retention. Key reminders included issues such as tailgating and ensuring babies wore two identification bands.

Staff who reported incidents received feedback, reinforcing a transparent reporting culture. For example, learning from a retinopathy of prematurity (ROP) screening incident, where a second screening was declined due to confusion, led to improved communication and clarity around parental understanding and consent.

Complaints were also used as learning opportunities, with reminders provided to staff on effective communication.

Governance and communication structures supported the dissemination of learning. Monthly meetings were held for Band 7 nursing leaders, with formal quarterly Band 7 meetings to review policy updates and national guidance (including NICE guidelines). Band 6 and Band 7 staff also had dedicated meetings, while Band 5 staff received updates via email and safety briefings.

In addition, the Band 7 nursing leaders delivered sessions for junior staff to share updates and promote team cohesion. Team study days and clinical supervision sessions further supported learning, with incident themes discussed regularly. Weekly “Top 3” learning points were also highlighted during nursing handovers.

An electronic system enabled effective oversight of staff compliance, including training and expiry dates, using a traffic light system to flag upcoming requirements. Band 7 leaders monitored their teams, with matrons maintaining overall oversight.

The education team played a key role in embedding learning. They provided bedside teaching, incorporated Patient Safety Incident Response Framework (PSIRF) findings into simulation training, and contributed to performance and quality reports. Simulation sessions were recorded and shared via Microsoft Teams to maximise accessibility.

Incidents were reviewed in line with PSIRF, and learning was disseminated across the service. This informed ongoing training programmes and was reflected in governance structures, including quality reports and clinical governance board displays.

We scored the service as 3. The evidence showed a good standard. The service worked with families and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

The service had effective systems and processes to maintain a safe and secure environment. There were effective security arrangements to manage access to the unit. For example, a facial recognition system was used for parents, and where access issues arose (such as a parent not being permitted entry), staff followed clear processes, including contacting the nurse in charge to manage the situation safely.

The transitional care unit (TCU) was used appropriately to support mothers and babies to remain together where additional clinical care was required. This provided a clear step within the pathway between maternity services and the neonatal unit. Staff followed established guidance in relation to the operation, referral criteria and treatments delivered within the TCU.

There was clear escalation pathways for babies on the postnatal ward. Staff were able to identify and escalate concerns promptly to ensure deteriorating babies were reviewed and transferred to the neonatal unit, where required.

Staff undertook regular training, including simulation exercises for baby abduction scenarios. This supported staff to respond effectively to potential incidents. Security arrangements were robust and included staff-controlled access systems, a parent facial recognition system, and clear signage to reduce the risk of unauthorised access, including tailgating.

The service participated in external governance processes, including the Child Death Overview Panel, to ensure learning from deaths and serious incidents was reviewed, shared and embedded into practice.

There were clear systems and policies to support the recognition and management of sepsis and perinatal infection. Staff understood their responsibilities in relation to early identification and escalation. Clinical pathways were in line with current best practice.

Leaders supported staff to attend regular ‘skills and drills’ sessions. These simulation-based activities enabled staff to practise and maintain competency in managing a range of clinical scenarios. Recent training included the stabilisation of a preterm baby with gastroschisis.

There was structured discharge planning processes. Parents received appropriate training and support prior to discharge where ongoing care needs were identified. The service also had access to a dedicated neonatal transport team, with appropriate clinical oversight, to support safe and timely transfers when required.

We scored the service as 3. The evidence showed a good standard. The service worked with families and healthcare partners to understand what being safe meant to them and the best way to achieve that. The service shared concerns quickly and appropriately.

The service worked collaboratively with families and partner agencies to improve outcomes for babies while protecting their right to live safely.

Safeguarding processes were effective and well embedded. A lead consultant for safeguarding worked collaboratively with network trusts to strengthen communication and oversight. Safeguarding leads met twice weekly with the wider team to review cases and consider potential referrals, with additional discussions taking place during daily safety huddles.

All staff completed Level 3 safeguarding training and demonstrated a good understanding of safeguarding responsibilities. They were able to recognise potential signs of concern, such as missed appointments, and understood how to respond appropriately. Staff were confident in managing safeguarding disclosures and identifying risks such as domestic abuse, using an open-questioning approach to support individuals in sharing concerns.

There was clear systems were for documenting and escalating safeguarding concerns, including the use of dedicated records and oversight from a safeguarding lead. Where necessary, the security and safeguarding teams worked together to manage risk, including safely escorting parents from the unit when concerns were identified.

The service worked closely with external partners, including the Local Authority Designated Officer (LADO), to ensure appropriate oversight and management of allegations involving those working with children.

Staff had access to multiple sources of support when making safeguarding referrals, including the learning and development hub, safeguarding partnerships, education safeguarding advisory teams, and outreach nurses.

The service also demonstrated a strong commitment to preparedness and learning through simulation training. Regular multidisciplinary simulations were undertaken, including baby abduction drills involving actors, with parents informed in advance. Staff responded appropriately during these exercises, demonstrating knowledge of escalation processes such as contacting security and the site coordinator. Additional simulations, including complex scenarios such as multiple births and neonatal transfers to theatre, were undertaken regularly (every other month). A member of the advanced neonatal nurse practitioner (ANNP) team had also completed a fellowship in simulation training, further strengthening the service’s training capacity.

We scored the service as 3. The evidence showed a good standard. The service worked with families to understand and manage risks by thinking holistically. Staff provided care to meet babies needs that was safe and supportive.

The service worked effectively with babies and their families to understand and manage risks, ensuring care was delivered safely and in line with individual needs.

There were well-established systems for identifying and escalating risks across the service. Trust-wide operational meetings were held five times daily, attended by the allocated “Bronze” lead, where capacity, safety concerns, and operational pressures were reviewed and escalated as required. In addition, a weekly clinical directors’ meeting provided oversight of paediatric services, including anticipated pressures and escalation planning for the week ahead.

A weekly triumvirate meeting brought together senior leaders, including the matron, deputy matron, clinical leads, and service managers across neonatal and paediatric intensive care services. These meetings reviewed performance, escalation risks, discharge planning, transport arrangements, and oversight of the human milk bank, which was managed in-house and supported local services.

The service demonstrated proactive risk identification through initiatives such as the “Red Hat” project. Babies identified as high risk at birth were highlighted due to the shared consultant cover across maternity and neonatal services. These babies were visually identified to ensure increased vigilance and early intervention, with the aim of reducing unplanned admissions to the neonatal unit.

Staff were appropriately trained to manage clinical risks. Neonatal Life Support (NLS) and resuscitation training were delivered face-to-face, while other training was supported through e-learning. Multidisciplinary simulation training took place twice weekly, involving both medical and nursing staff, and was shared with midwifery teams to strengthen responses to maternity-related scenarios.

We reviewed 10 baby records and found they contained up-to-date observations, demonstrating consistent monitoring of babies’ clinical condition.

Daily routines supported safe care delivery. Morning and afternoon board rounds, alongside daily safety huddles, ensured risks were reviewed, prioritised, and communicated effectively across the team.

Safety checks were embedded into practice. Emergency resuscitation trolleys, SEND equipment, and blood glucose monitoring devices were checked daily to ensure readiness for use.

Care records also reflected adherence to national guidance. For example, documentation confirmed whether newborn babies had received vitamin K, which is routinely recommended shortly after birth to prevent vitamin K deficiency bleeding (VKDB), a potentially serious condition.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure facilities supported the delivery of safe care.

The service did not always ensure that facilities supported the delivery of safe care. While some risks were identified and managed, environmental and estate limitations continued to impact on care delivery.

The environment did not always meet the needs of babies and families. For example, the bereavement suite did not have direct access to toilet facilities, which meant families had to go to the ward to use the toilets when they had received sensitive information, which did not support privacy or dignity during sensitive situations. All three units shared one visitor’s toilet meaning facilities for families were limited. Families we spoke with advised the toilet was often in use; therefore, they used the facilities in the main corridor outside the department and elsewhere in the hospital.

The physical layout of the service presented additional challenges. The distance between the neonatal unit and theatres was significant, and while surgical teams would attend the unit to perform procedures for critically unwell babies, this placed additional pressure on staffing and resources within the department. Staff used the bereavement room or a nurses’ office for sensitive conversations. However, when the bereavement room was occupied, discussions had to take place in a nurses’ office, which was not always an appropriate environment for confidential and sensitive conversations. However, funding for a new bereavement space had been secured through charitable support.

There were known estate risks within the HDU. The main risk was the limited space within the unit. To mitigate this risk, the service had strict policies regarding capacity and would keep babies on the NICU for longer periods if there was not space on the HDU. Equipment, including digital workstations, was bulky and difficult to manoeuvre within the limited space. The service had explored improvements such as slimline carts and increased use of portable devices, and wider refurbishment options were being considered through a business case as part of the perinatal strategic programme.

Space constraints in HDU, particularly on Elm Ward, impacted on both safety and baby experience. The environment was cramped, limiting staff movement during emergencies and reducing privacy for families. For example, mothers were sometimes required to breastfeed without adequate screening due to lack of space. Isolation facilities were also limited.

Families advised us they found the differences in environment a challenge when moving from the NICU to the HDU. One family said to us “The NICU has lots of space, we had lots of privacy to bond with our baby and do skin to skin. We’re so glad they are making progress and no longer needing the NICU, but the HDU feels like a completely different trust”. Another family said “I cannot fault the staff, they work so hard but are very cramped in this unit. It must be very difficult to work here day in day out”.

Storage limitations were also identified, particularly within the LDU, where equipment overflow was stored in HDU areas, contributing to congestion and reduced usable space.

The wider estate presented ongoing challenges. The neonatal unit was located in what was initially a temporary location; however, it had been there since 2016. There were known infrastructure limitations, including the presence of asbestos, with surveys ongoing. Senior leaders were reviewing estates improvement as part of a trust-wide perinatal improvement programme. The programme had oversight at local, divisional, and executive level.

Staff told us that the pace of change within the organisation could be slow, even when making relatively minor environmental improvements. For example, changing the décor in parent rooms had taken a significant amount of time due to internal processes.

The layout did not consistently align with national guidance, for example NHS England recommends sufficient space between cots (at least 1.5 metres clearance) to allow safe access, emergency response, and dignity for families. The service was in breach of a regulation related to the environment.

Despite these challenges, risks were assessed and mitigated where possible. For example, there had been no reported incidents where staff were unable to access a baby in an emergency on the HDU, and there was contingency arrangements, including the use of treatment rooms if a baby’s condition deteriorated. Infection prevention and control risks were monitored and audited, including during outbreak situations.

The service recognised environmental risks within the unit and had initiated a number of workstreams to address these, including participation in a third-party programme and a wider perinatal estate review. These actions demonstrated that leaders were aware of the limitations of the physical environment.

However, when reviewing the local, directorate and divisional risk registers, we found inconsistencies in how these risks were recorded and escalated. Environmental risks were rated as ‘yellow’ on both the local and directorate risk registers and were not included on the divisional risk register. This suggested that the level of risk may not have been fully reflected within the organisation’s governance systems. As a result, the prioritisation and pace of change to address environmental concerns was slow, which could impact on the service’s ability to mitigate known risks in a timely way.

The service provided evidence of water safety testing, including Legionella testing. There was safe fire safety processes, and staff were up to date with mandatory fire training. Clinical engineering support and portable appliance testing (PAT) were also established. Following a fire incident in the maternity service, departments reviewed their fire procedures, and Band 6 staff had undertaken fire coordinator training, supported by designated fire marshals. However, fire evacuation drills had not yet been completed, although these were planned.

The service had enough Resuscitaires, and we observed that there was a maintenance, servicing and replacement programme. Other environmental risks had been identified and mitigated, for example, ligature risks.

We scored the service as 2. The evidence showed some shortfalls regarding supervision ratios and high vacancy rates in some bands.

During the inspection our team raised concerns regarding the ratio of substantive consultants to resident doctors. Current supervision arrangements were not fully aligned with best practice, and this imbalance was reported to place additional pressure on nursing staff, particularly in supporting less experienced medical colleagues. The unit had 12 whole-time equivalent (WTE) substantive consultants and 1.5 WTE locum consultants in post. Locum consultants were employed to cover vacancies, enabling the unit to meet its funded establishment of 13.5 WTE consultants.

The service had areas of workforce challenge, with high vacancy rates across support staff roles. At the time of inspection, vacancy rates were 35% for Band 4 staff, 73% for Band 3 staff and 77% for Band 2 staff. Whilst these percentages constituted less than 10 members of staff, these shortages placed additional pressure on existing staff and had the potential to impact the delivery of care and support services.

Staff feedback reflected these concerns. Results from the most recent staff survey showed that only 19% of neonatal staff felt there were enough staff at the organisation for them to do their job properly. This indicated a lack of confidence among staff in workforce capacity and highlighted ongoing risks to service sustainability.

Although vacancy rates were high, the service used an established safe staffing tool, and staffing levels were reviewed through multiple daily meetings at local, divisional, and trust level. These included critical care staffing meetings, divisional safety huddles, and trust-wide operational meetings. Staffing could be escalated and redeployed as required, including across sites within the trust as well as the usage of bank and agency staff.

Staff on the unit also described tensions between day and night teams, with some day staff perceiving that workload was not shared equitably. This had contributed to a divide between teams and affected morale. Additionally, some staff raised concerns about reduced oversight on night shifts, as there was no dedicated doctor or coordinator present on the LDU overnight. While these concerns had been raised with team leaders, staff felt that actions taken were not consistently followed up or effectively monitored, which led to a perception that issues were not fully addressed. However, we found no evidence of incidents related to these concerns.

There were also challenges in relation to neonatal nursing qualifications. British Association of Perinatal Medicine (BAPM) standards recommend that 70% of neonatal nurses are Qualified in Specialty (QIS). The trust’s QIS compliance rate was 51% in 2025, with a planned increase to 59% in 2026. Projections indicated that the 70% target would not be achieved until 2028.

Despite this, there were clear systems to support staff development. Band 5 nurses were supported to work towards QIS status as part of their progression to Band 6, with protected time for training built into the rota. There was a structured development programme for nurses transitioning from High Dependency Unit (HDU) to Neonatal Intensive Care Unit (NICU), including a comprehensive induction covering respiratory, neurological, and cardiovascular care, as well as advanced interventions such as ventilator management and cardiovascular support. This was supported by a six-week supernumerary period.

Staffing numbers were in line with the British Association of Perinatal Medicine (BAPM) and Advanced Neonatal Nurse Practitioners (ANNPs) guidance. These standards ensure there is a minimum 1:1 nurse-to-patient ratios in intensive care, 1:2 ratio in a high dependency unit, and 1:4 in a low dependency unit. Therefore, the service ensured there was sufficient staff to provide safe care and treatment.

Training provision included face-to-face and simulation-based learning, alongside a two-tier training model incorporating both deanery and trust-led education. Team development days supported both training compliance and team cohesion.

Governance systems supported oversight of workforce capability. Appraisals were aligned with mandatory training processes, with a structured two-month appraisal window to ensure consistency across teams. Staff received mid-year reviews to assess progress and identify additional support needs.

The service had implemented several initiatives to strengthen workforce culture and capability. Professional Nurse Advocates had been introduced, and there was a clear focus on developing healthcare assistants into more baby-facing roles. A distinct management structure for nursery assistants had also been established to improve role clarity and leadership.

The service also worked collaboratively across the wider network, participating in twice-weekly regional staffing reviews with neighbouring trusts to maintain safe staffing levels across the system. Recruitment was actively managed through weekly meetings, with oversight of vacancies, advertising, and candidate support.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service effectively assessed and managed the risk of infection. Staff demonstrated good practice in detecting, preventing, and controlling the spread of infection.

Each ward had a comprehensive cleaning schedule, clearly outlining cleaning tasks, responsibilities, and required frequency. This supported consistency and accountability in maintaining a clean environment.

Across the unit, the trust’s commitment to cleanliness was clearly displayed, including information for parents and visitors on how they could support infection prevention and control measures.

Hand hygiene facilities were readily available. Hand sanitiser stations were well stocked and located throughout the department, and handwashing facilities were positioned at the entrance to all three units. Parents and visitors were actively encouraged to clean their hands on entry to reduce the risk of infection transmission.

Staff adhered to the trust’s uniform policy and national guidance, including maintaining “bare below the elbows.” We observed staff consistently using effective handwashing techniques, supported by clear visual prompts displayed at sinks demonstrating correct hand hygiene practices.

Cleanliness standards were consistently high across all three neonatal areas. Each unit had achieved a cleanliness rating of four or five out of five stars, with cleaning audit scores in the high 90s. Recent hand hygiene audits demonstrated a compliance rate of 96%. During inspection, all areas, including both high- and low-level surfaces, were visibly clean.

The service also used a clear and effective colour-coded system for managing laundry. This ensured appropriate handling of different types of linen, including infected, soiled, clean, and rejected items, reducing the risk of cross-contamination.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met babies’ needs, capacities and preferences. They involved families in planning, including when changes happen.

The service made sure that medicines and treatments met babies’ needs and preferences.

The on-site pharmacy team maintained oversight to ensure medicines were prescribed, stored and ordered in line with best practice across the department.

Electronic prescribing had been introduced across the service. Initial audits identified an increase in medicines errors following implementation; however, ongoing monitoring and targeted actions had led to a significant reduction in errors over time. The service continued to audit prescribing practices and monitor trends to support sustained improvement.

Staff completed daily checks of medicine fridge and room storage temperatures. Staff understood the escalation processes when temperatures fell outside of the acceptable range. Temperature logs were consistently completed and signed off by a senior member of staff, such as a ward manager, ward pharmacist or medicines management technician, providing additional assurance and oversight.

Sharps bins were appropriately labelled, securely assembled and not overfilled beyond the designated fill line. The unit used the trust’s approved sharps disposal service, supporting safe and compliant waste management.

Oxygen cylinders were stored safely in accordance with national guidance. Full and empty cylinders were kept separately and clearly identified, reducing the risk of staff inadvertently selecting an empty cylinder.

We reviewed milk storage arrangements and saw that all containers were clearly labelled to ensure babies received the correct mother’s milk. There were established systems to support the donation of breast milk when mothers had trouble breastfeeding or expressing. Donor mothers underwent appropriate screening, including blood tests such as HIV, to ensure the safety of donated milk. All milk was clearly labelled with expiry dates. The service advised they were planning to introduce a pasteuriser in summer 2026.

Controlled drugs were prescribed, stored, administered and recorded in line with national guidance. We checked controlled drug records across all three wards and found they were complete, accurately maintained and signed by two members of staff in accordance with policy. We checked stock balances and noted they matched.