CQC Churchill report

This report describes our judgement of the quality of care at this hospital. It is based on a combination of what we foundwhen we inspected, information from our 'Intelligent Monitoring' system, and information given to us from patients, thepublic and other organisations.

Ratings

Overall rating for this hospital Good –––

Medical care Good –––

Surgery Good –––

Intensive/critical care Good –––

End of life care Good –––

Outpatients Good –––

Oxford University Hospitals NHS Trust

ChurChurchillchill HospitHospitalalQuality Report

Old RoadHeadingtonOxfordOX3 7LJTel: 01865 226055Website: www.ouh.nhs.uk

Date of inspection visit: 25-26 February and 3 March2014

Date of publication: 14 May 2014

1 Churchill Hospital Quality Report 14 May 2014

Contents

PageSummary of this inspectionOverall summary 3

The five questions we ask about hospitals and what we found 4

What we found about each of the main services in the hospital 6

What people who use the hospital say 9

Areas for improvement 9

Good practice 10

Detailed findings from this inspectionOur inspection team 11

Background to Churchill Hospital 11

Why we carried out this inspection 12

How we carried out this inspection 12

Findings by main service 0

Action we have told the provider to take 49

Summary of findings


Overall summary

The Churchill Hospital first opened in 1942 during the waras an American Hospital; it was taken over in 1946 byOxford City Council and integrated with the JohnRadcliffe Hospital in 1993. There are 217 in-patients beds,8 critical care high dependency beds, 10 theatres, daycare and outpatient facilities. The Churchill Hospital inHeadington is the site of the Oxford Cancer Centre and acentre for renal and transplant services, medical andsurgical services, oncology, dermatology, haemophilia,infectious diseases, respiratory medicine, medicalgenetics, palliative care and sexual health.

To carry out this review of acute services we spoke topatients and those who cared or spoke for them. Patientsand carers were able to talk with us or write to us before,during and after our visit. We listened to all these peopleand read what they said. We analysed information weheld about the hospital and information fromstakeholders and commissioners of services. Peoplecame to our two listening events in Banbury and Oxfordto share their experiences. To complete the review wevisited the hospital over two days, with specialists andexperts and carried out an unannounced visit. We spoketo more patients, carers, and staff from all areas of thehospital on our visits. The regulatory activities diagnosticand screening procedures, surgical procedures,treatment of disease, disorder or injury were inspected.

StaffingStaff were positive about working at the hospital theysaid it was a supportive environment in which to work.Where staffing levels were a concern wards were able touse agency and bank staff to maintain safe staffing levels.In cases where this was not possible beds would beclosed. The hospital was actively recruiting to vacateposts.

Cleanliness and infection controlThe hospital was found to be clean. Some areas of thehospital were found to be old, tired and worn. Handwashing facilities were readily available as was handcleansing gel. Staff cleaned their hands between patientsand this was supported by the feedback given bypatients. It was observed that staff observed the hospitalbare below the elbow policy. Infection control nurseswere available to support staff and audits wereundertaken to monitor practice. The trust’s infection ratesfor Clostridium difficile and MRSA lie within a statisticallyacceptable range for the size of the trust. In the last threemonths there had been no incidents of MRSA cases at thishospital.

Summary of findings


The five questions we ask about hospitals and what we found

We always ask the following five questions of services.

Are services safe?Services at the hospital were safe. Staff were trained and responsive to anysigns of abuse and avoidable harm. Patients reported that they felt safe. Therewere established systems for the reporting of incidents and there wereprocesses for the sharing of learning from the outcome of any investigations.The hospital was clean and infection control protocols were followed.Medicines were managed safely.

Staffing levels were acceptable with systems in place to manage when staffinglevels had the potential to impact on patient safety. Some of the older areas ofthe hospital are looking tired and worn and had the potential to place staffand patients at risk. The trust was aware of this and this was included on thehospitals risk register. When patients lacked the capacity to make decisions,the requirements of the Mental Capacity Act 2005 and multidisciplinarydecisions acting in people’s best interests were followed.

Good –––

Are services effective?Outcomes for patients were good. National guidelines and best practice wereapplied and monitored. Pain management was done well. Staff worked inmultidisciplinary teams to coordinate care around a patient. End of life carewas integrated across the hospital and patients and staff were complimentaryabout this service. The critical care service provided excellent care with goodoutcomes. While staff had access to the equipment they needed the actualmaintenance program was not clear and staff on the wards were not alwaysaware of when equipment had last been serviced. There was a centralmaintenance programme with records held on a corporate database, but staffon wards were not aware of this.

New staff were supported through an induction program and students weresupported by mentors. Staff were provided with core mandatory training.Concerns had been identified with the integrated care pathway for inpatientswith diabetes and the trust was actively working to address this. On themedical wards care plans were not always current and up to date andreflective of patients’ agreed care needs.

Good –––

Are services caring?During our inspection, we observed staff were caring and patients weretreated with dignity and respect. Staff in the critical care team providedoutstanding care and emotional support. End of life care, which was providedacross the hospital where needed, was caring, professional and supportive topatients’ choices. When patients lacked the capacity to make decisions, therequirements of the Mental Capacity Act 2005 and multidisciplinary decisions

Good –––

Summary of findings


acting in people’s best interests were followed. Where every possible patientsand their families were involved in the decision making process. Informationwas available in languages other then English for those whose first languagewas not English.

Are services responsive to people’s needs?The hospital supported vulnerable patients well, to ensure care was deliveredin their best interests. Discharge arrangements were a challenge. The trust wasactively working with partners to improvements to the internal and externaldischarge arrangements so that people who do not require a hospitalenvironment are discharged to community services timely and effectively.Arrangements were in place to support those who did not speak English andmight need additional assistance and adjustments to enhancecommunication whilst in hospital.

Good –––

Are services well-led?Generally staff were aware to of the trusts vision and values. Staff felt thehospital was well led at local and directorate level. Staff were supported bytheir peers and managers to deliver good care and to support one another.There was an appraisal system in place to support staff, which most staff hadcompleted. The trust actively sort and considered feedback from patientsthrough survey s and the friends and family test. During 2012 the trustlaunched a five year vision for the organisation, which included the Churchillhospital, and which aimed to deliver continuous quality improvement with afocus on three key areas for 2013 / 14: patient safety, patient experience andclinical effectiveness. This showed the commitment of the hospital to engagewith improving services to patients.

Good –––

Summary of findings


What we found about each of the main services in the hospital

Medical care (including older people’s care)Patients received safe care and were protected from risks. Infection rates werelow and the hospital was clean. However, risks to people’s safety increasedduring busy times. Medical patients were transferred to surgical wards and didnot always see a specialist in a timely manner. Some equipment needed to bebetter maintained and some areas were in need of refurbishment. Patientrecords needed to include accurate and appropriate information.

Staffing levels were regularly monitored to ensure wards and departmentswere staffed with the right number of staff with the skills and knowledge tomeet people’s needs. The hospital continued to recruit into vacancies.

Integrated care pathways for inpatients with diabetes were still beingformalised. In the trust diabetes affects 14.7% of adult inpatients. The diabetesquality group was responsible for the monitoring and delivery of the “ThinkGlucose” project to improve the quality of care. Diabetes specialist nurseswere to be recruited and training was also being delivered to ensure thatinpatient diabetes treatment protocols were implemented effectively andconsistently in line with national guidance.

Some patients had multiple health, social and/or psychological needs whichrequired the input of several specialist teams. The multidisciplinary teams inthe division were well integrated and had a strong collaborative approach tocare. Care and treatment that was agreed and delivered was not alwaysrecorded. A written record was not always available to all parties to ensurecontinuity of care.

Staff were caring. Patients and relatives told us they were treated with dignity,compassion and respect. Patients were involved in planning their treatmentand staff knew how to protect the rights of patients who lacked capacity tomake decisions about their treatment.

The hospital staff faced significant challenges when discharging patients tocommunity services. They were working with stakeholders to deliver thedischarge improvement programme including improving medicationdischarge arrangements.

The service was well-led. Clearly defined governance arrangements were inplace in the division which led to improvements in quality. Staff felt supported,valued and proud to be part of the organisation. Opportunities were availablefor staff to develop their leadership skills. Patients and staff informed servicedelivery and their views were understood at division and trust board level

Good –––

SurgeryThere was consensus amongst patients, carers and staff that staff werededicated and provided compassionate, empathetic care. Processes werefollowed to reduce any risks to patients undergoing surgical treatment.

Good –––

Summary of findings


Staff made use of the language line facility and interpreters to ensure patientshad a good understanding of their treatment and were able to make informeddecisions.

Staff had a good understanding of the Mental Capacity Act 2005 which meantpatients received the appropriate support to be able to make their owndecision, or where required decisions involving appropriate people weremade in the best interest of the patient.

Generally there was sufficient equipment available to meet the needs ofpatents. However, concerns were expressed about access to radiology forsome patients. This meant that patients had to undergo radiographyprocedures on the day of their planned surgery, rather having allinvestigations completed prior to the day of planed surgery.

There was evidence that learning from incidents occurred and that changeswere being made in response to findings from quality auditing processes.

We saw good evidence of team working at ward and departmental level.

Intensive/critical carePatients received safe care. Clinical outcomes were monitored anddemonstrated good outcomes for patients. Care provided was effective with amultidisciplinary approach taken and good standards of facilities to meetpatient’s needs. Whilst staff recruitment and retention was recognised by thetrust as an issue, the levels and skills of staff on a day to day basis wereconsistently managed by using staff from John Radcliffe Hospital.

Patients told us the kindness and care of staff was outstanding. The unit wasresponsive to the needs of the patient and learned from safety events orincidents. The departments were well led and demonstrated a positiveleadership and open culture to enable staff to feel involved in changes.

Good –––

End of life carePatients received effective and sensitive end of life care. Patients told us theyfelt safe and their needs were met by skilled staff. Patients knew the reasonsfor their admissions and had made decisions about where to have their end oflife care. Patients’ pain was well managed by the clinical staff and they did nothave to wait for their medicines. Staff respected patients’ rights and, inparticular, their privacy and dignity.

Palliative patients were able to make decisions about the medical proceduresto be followed in the event of a cardiopulmonary arrest. If the decision wasnot to resuscitate in the event of a cardiopulmonary arrest, the decision wasrecorded and professionals made aware of the decision.

Patients were cared for with compassion by staff who knew how to care forpatients at the end of their life. Hospital staff attended palliative care trainingand were able to attend study days on end of life care to update theirknowledge.

Good –––

Summary of findings


Palliative patients had access to a centralised helpline which offered adviceand referrals for admissions. End of life patients arriving on the emergencymedical unit were assessed and transferred to the most appropriate ward tomeet their care and treatment needs.

Systems were in place to provide sensitive care to patients on end of lifepathways and their families. Haematology palliative patients were able toreceive treatment as day patients in a recently opened ambulatory roomenabling them to remain longer in their own homes. A four-bed flat wasavailable on site for families who wanted to be close to their relative duringtheir end of life pathway.

OutpatientsPatients received safe and effective care. Some outpatient and day serviceswere in an old part of the hospital not well suited to the delivery of modernday healthcare. We saw that this was recorded in the risk register and thattemporary actions had been taken to mitigate the risk. Identified remedialwork had not been undertaken and genetics and cystic fibrosis servicesaffected had not been relocated as planned. We were not able to establishwhen this would be completed. The clinics we visited were well led andpatients told us that the care was excellent.

Good –––

Summary of findings


What people who use the hospital say

In the November 2013 friends and family test, 47 wards atOxford University Hospitals NHS Trust were included.There were 13 wards that scored less than the trustaverage of 68. Geoffrey Harris Ward the specialistmedicine ward at the Churchill hospital was one of these.

From the NHS Choices website there were five commentsrelating to the Churchill Hospital that were rated fivestars, themes from this included; excellent Urology ward,excellent care, professionalism, went that extra mile,dedication and commitment. There was also onecomment rated as one start, the theme’s coming fromthis comment were; poor people skills, poor dermatologyward, lack of listening and lack of respect & dignity. Thestars ratings on the NHS Choices website give ChurchillHospital a score of 4.5 stars (out of a total of 5) for‘cleanliness’ ; 4.5 stars for ‘staff co-operation’ ; 4.5 stars for‘dignity and respect’; 4.5 stars for ‘involvement indecisions’ ; 4 stars for ‘same-sex accommodation’ .

From the Adult Inpatient Survey 2012 the trust performedwithin expectations for all ten areas of questioning. Theserelate to the areas the emergency department,; waiting

list and planned admissions; waiting to get to a bed on award; the hospital and ward; doctors; nurses; care andtreatment; operations and procedures; leaving hospital;overall views and experiences.

Out of a total of 60 questions, the trust performed betterthan other trusts in two questions and worse than othertrusts for none of the questions. The two positivequestions were did a member of staff explain the risksand benefits of the operation or procedure? and were youtold how you could expect to feel after you had theoperation or procedure?

Within the Adult Inpatient Survey, there are two questionsthat refer to the process of discharge. These relate to theproportion of respondents to the adult inpatient surveywho stated they were not given enough notice aboutwhen they were to be going to be discharged and theproportion of respondents to the adult inpatient surveywho stated that their discharge was delayed for morethan four hours, due to waiting for medicine, to see adoctor or for an ambulance. The trust scored similar toexpected when compared with other trusts.

Areas for improvement

Action the hospital MUST take to improveOn the medical wards the trust must ensure that patientrecords accurately reflect the care and treatment plannedand delivered for each patient in line with clinicalguidelines and good practice standards.

Action the hospital SHOULD take to improve

• Consideration should be given to the management ofthe outpatient clinics in the older parts of the hospital.Particular consideration should be given to thepatient’s well fare and their health and safety. This isbecause of the limited space in some areas and thegeneral condition of some of the facilities.

• The trust should continue making improvements tothe internal and external discharge arrangements sothat people who do not require a hospitalenvironment are discharged to community servicestimely and effectively.

• Identified shortcomings in the care and treatmentpathway of inpatients with diabetes were beingaddressed but the trust needs to ensure thatoutcomes are delivered to these patients in line withgood practice and clinical guidelines.

• The trust should continue with its recruitment effortsto ensure that sufficient medical beds are available topatients and safe staffing levels are maintained.

• Identified concerns relating to the facilities in the olderpart of the hospital were being addressed but the trustneeds to ensure that suitable well maintainedpremises are available to patients and staff.

• Codes used to inform staff of the medical proceduresto be followed for specific patients in the event of apatient having a cardiopulmonary arrest should bestandardised across the hospital.

Summary of findings


Good practice

Our inspection team highlighted the following areas ofgood practice:

• Patients and their families were positive about theirexperience in the critical care unit. They felt that theyhad been involved, kept informed and treated withdignity and respect at all times. They felt that both themedical and the nursing team took time to build atrusting relationship before and during the experience.

• Staff worked well between teams. The value off aneffective multi-disciplinary approach, in improvingoutcomes for patients, was understood and activelyencouraged.

• It was evident that significant efforts had been beingmade to improve the effective discharge of patients.The hospital was working closely with commissioners,social services and providers to improve the transfer ofpatients to community services.

• The trust internal peer review process, in which over100 clinical areas had been reviewed in a three monthperiod across the trust.

Summary of findings


Our inspection teamOur inspection team was led by:

Chair: Dr Chris Gordon Director, Foundation TrustSupport Programme at NHS Top Leaders, Department ofHealth & Consultant Physician at Hampshire HospitalsFoundation Trust

Head of Hospital Inspections: Mary Cridge CareQuality Commission

The team of 51 included CQC inspectors, managers andanalysts, consultants and doctors specialising inemergency medicine, obstetrics and gynaecology,oncology, diabetes care, cardiology and paediatrics . Italso included junior doctors, a matron, nursesspecialising in care for the elderly, end of life care,children’s care, theatre management, cancer andhaematology and two midwives together with patientand public representatives and experts by experience.Our team included senior NHS managers, including twomedical directors, a deputy chief executive, a clinicaldirector in surgery, critical care and a director ofoperations in the acute and community sector.

Background to ChurchillHospitalThe Churchill Hospital is a centre for cancer services andother specialities, including renal services and transplantservices, clinical and medical oncology, dermatology,haemophilia, infectious diseases, chest medicine, medicalgenetics and palliative care.

Developments in recent years include the opening of theOxford Centre for Diabetes, Endocrinology and Metabolism(OCDEM) - collaboration between the University of Oxford,the NHS and three partner companies, to create a centrefor clinical research on diabetes, endocrine and metabolicdisorders, along with clinical treatment and education.

The hospital, together with the nearby John RadcliffeHospital, is a major centre for healthcare research, housingdepartments of Oxford University Medical School andOxford Brookes University's School of Healthcare Studies.

There is an integrated Cancer and Haematology Centre, aSurgery and Diagnostics Centre and the Wytham Wing -housing the Wytham Ward (transplant) and privateoutpatients. These centres bring together a wide range ofmedical and surgical services including cancer medicine(clinical and medical oncology, clinical haematology andradiotherapy), surgery (gastrointestinal, breast, andgynaecological cancer and non-cancer surgery), diagnosticservices (laboratories, radiology and breast screening) anda base for University research teams, working inpartnership with NHS colleagues.

ChurChurchillchill HospitHospitalalDetailed Findings

Services we looked at:Medical care (including older people’s care); Surgery; Intensive/critical care; End of life care; Outpatients


This location has been inspected twice on 11 July 2011 and12 July 2011. The location was found to be compliant withtwo outcomes care and welfare of people who use servicesand staffing although there were minor concerns forsupporting workers and assessing and monitoring thequality of service provision.

Why we carried out thisinspectionWe inspected this hospital as part of our in-depth hospitalinspection programme. We chose this hospital becausethey represented the variation in hospital care according toour new intelligent monitoring model. This looks at a widerange of data, including patient and staff surveys, hospitalperformance information and the views of the public andlocal partner organisations. Using this model, ChurchillHospital as part of Oxford University Hospitals NHS Trustwas considered to be a medium risk level service.

How we carried out thisinspectionTo get to the heart of patients’ experiences of care, wealways ask the following five questions of every service andprovider:

• Is it safe?

• Is it effective?• Is it caring?• Is it responsive to people’s needs?• Is it well-led?

The inspection inspected the following core services ateach inspection:

• Medical care (including older people’s care)• Surgery• Intensive/critical care• End of life care• Outpatients.

Before visiting, we reviewed a range of information we holdabout the hospital and asked other organisations to sharewhat they knew about the hospital.

We carried out an announced visit on 25 and 26 February2014 and an unannounced visit on 2 March 2014. Duringthe visit we held drop in sessions for all staff. We talked withpatients and staff from all areas of the hospital includingthe wards, theatre, outpatient departments and criticalcare unit . We observed how people were being cared forand talked with carers and/or family members andreviewed personal care or treatment records of patients.

We held a listening event where patients and members ofthe public shared their views and experiences of thelocation.

Detailed Findings


Safe Requires Improvement –––

Effective Good –––

Caring Good –––

Responsive Good –––

Well-led Good –––

Information about the serviceThe Churchill Hospital provided care and treatment forpeople on three medical wards. The wards provided thefollowing specialities: renal, respiratory, diabetes,endocrinology, infectious diseases and tropical medicine.We visited the medical wards and talked with six patientsand ten staff including nurses, doctors, therapists andsupport staff. We observed care and treatment and lookedat care records. We received information from our listeningevents, focus groups, interviews and comment cards. Weused this information to inform and direct the focus of ourinspection. Before our inspection we reviewedperformance information from, and about, the trust andhospital.

Summary of findingsPatients received safe care and were protected fromrisks. Infection rates were low and the hospital wasclean. However, risks to people’s safety increased duringbusy times. Medical patients were transferred to surgicalwards and did not always see a specialist in a timelymanner. Some equipment needed to be bettermaintained and some areas were in need ofrefurbishment. Patient records needed to includeaccurate and appropriate information.

Staffing levels were regularly monitored to ensure wardsand departments were staffed with the right number ofstaff with the skills and knowledge to meet people’sneeds. The hospital continued to recruit into vacancies.

Integrated care pathways for inpatients with diabeteswere still being formalised. In the trust diabetes affects14.7% of adult inpatients. The diabetes quality groupwas responsible for the monitoring and delivery of the“Think Glucose” project to improve the quality of care.Diabetes specialist nurses were to be recruited andtraining was also being delivered to ensure thatinpatient diabetes treatment protocols wereimplemented effectively and consistently in line withnational guidance.

The multidisciplinary teams in the division were wellintegrated and had a strong collaborative approach tocare. Care and treatment that was agreed and deliveredwas not always recorded. A written record was notalways available to all parties to ensure continuity ofcare.

Medical care (including older people’s care)

Good –––


Staff were caring. Patients and relatives told us theywere treated with dignity, compassion and respect.Patients were involved in planning their treatment andstaff knew how to protect the rights of patients wholacked capacity to make decisions about theirtreatment.

The hospital staff faced significant challenges whendischarging patients to community services. They wereworking with stakeholders to deliver the dischargeimprovement programme including improvingmedication discharge arrangements.

The service was well-led. Clearly defined governancearrangements were in place in the division which led toimprovements in quality. Staff felt supported, valuedand proud to be part of the organisation. Opportunitieswere available for staff to develop their leadership skills.Patients and staff informed service delivery and theirviews were understood at division and trust board level.

Are medical care services safe?

Requires Improvement –––

Safety and performanceSystems were in place to report, respond and monitorsafety issues across all levels within medical care.

The hospital used the “safety thermometers” to measuretheir risk performance. The NHS Safety ThermometerReport 2012 - 2013 showed a fluctuating performance fornew pressure ulcers, falls, venous thromboembolism (VTE)and patients with catheter related urinary tract infections.

We saw the outcome of a recent audit to monitor thenumber of patients who were screened for venousthromboembolisms on admission to the Churchill hospital.The audit showed 87% compliance which was below thetrust’s quality target of 95%. We spoke with the actingdivisional head of nursing and governance to understandthis performance. They told us that the division hadimproved the assessment of patients for VTE whichresulted in a sudden decline in patients developingthrombosis across the trust. Some areas still requiredimprovements and action had been taken to ensure thatdoctors undertook the assessment and VTE screening forpatients on admission.

Pressure ulcers and falls remained a concern for thedivision and action plans were in place to improve themanagement of people at risk of falls and pressure ulcers.Work had also been done to ensure that the same fall wasnot recorded multiple times as an incident which hadhappened in the past.

Learning and improvementFollowing the investigation of grade three and fourpressure ulcers, a new pressure ulcer management policywas introduced. To prevent grade one and two pressureulcers from deteriorating these were now also recordedand monitored closely. A new tissue viability nurse hadbeen appointed to support the medical wards to managepressure ulcers effectively. Training in the new policy wasprovided to staff. Investigations of incidents weremonitored at the monthly quality meeting to ensure thatthey were completed in a timely manner and learningshared.


Good –––


Systems, processes and practicesStaff told us they had access to appropriate and suitableequipment within the hospital to provide care andtreatment. We observed that equipment like syringe driversand electro cardiograph machines had dates recorded onthem which showed they had not been checked or servicedrecently. One service date we saw was in 2011 and anotherin 2003. Some did not have any date or asset numberrecorded. We reviewed the trust policy and procedureregarding the management of medical devices. Thisspecified that all test equipment should be calibratedannually (unless indicated otherwise) and currentcalibration certificates retained. Medical equipment whichhad been purchased by individual wards was detailed in alog held by the housekeeper. During discussions with themanager of the technical engineer department we weretold there was an electronic database held of all themedical equipment used in the trust. It was acknowledgedthat some equipment would not be reflected on this list ifpurchased by wards who had then not advised thedepartment of its existence. We heard equipment was notroutinely maintained or serviced according to a fixedannual schedule. An appropriate service schedule wasdetermined for items of medical equipment at the point ofentry to the trust. In some cases, the service schedulemight involve no routine maintenance unless a fault wasreported to the department.

Some facilities and buildings were not well maintained atthe Churchill Hospital. The hospital had been expandedover the years. Some parts of the hospital were in a state ofdisrepair, with windows that did not close, leaks throughceilings and windows in areas that were used by patientsrequiring refurbishment. We saw the older part of thehospital had doors which accessed the outside that couldnot be locked or secured at night. When it rained the floorbecame wet and was a slip hazard. Security cover was notprovided across the 24-hour period, with a two hour gap inthe morning and a one hour gap in the evening. Thesecurity person could also be called away to attend otherhospitals across the trust if the need arose. This wouldleave the Churchill hospital without security, with staff andpatients potentially at risk. The security guard locked theexternal doors and held the keys. Their absence from thesite as given as to the reason why the large access doorswere not kept locked. The trust had identified theseconcerns relating to the Churchill estate environment. Thetrust risk register noted concerns with ‘‘poor environment

and building fabric for John Warin ward’’ as well as‘‘building problems due to the design of the Oxford Centrefor Diabetes, Endocrinology and Metabolism (OCDEM)building including Geoffrey Harris ward’’. Actions werebeing taken to manage the temperature, leaks and noise.Several business cases were also being drafted forrelocation of some services. The risk register noted thatthere had been some delays in completing actions and itwas recorded that ‘‘Problems with lack of progress havebeen escalated to directorate and are currently beingescalated to executive level’’.

Medication used on the ward was stored securely and theclinical room was accessed by a key pad style lock. We weretold that only staff who required access were provided withthe code to this room. Resuscitation trolleys were locatedthroughout the wards and the emergency medicationsheld on these were regularly checked to ensure they werein date. The pharmacy prepared the emergencymedication boxes and sealed them, while ensuring thedates of medication contained within were visible forchecking.

Medication monitoring systems were not consistentlyimplemented in line with quality standards. Drug treatmentcharts showed that staff did not always record medicationthat had been administered to patients during theprocedure of renal dialysis. This did not enable effectivemonitoring of the patient’s drug treatment. We found thatthe manufacturer’s guidelines for the storage of a liquidmedication had not been followed and the medicationcould have become ineffective. A medication audit hadbeen undertaken across the medical division and actionswere in place to ensure that medication was managed inline with quality standards.

Monitoring safety and responding to riskNursing and medical staff told us the staffing levels on thewards were generally at a level to enable them to providesafe care and treatment to patients, although at times theywere at minimal levels. They added that agency and banknurses often worked on the wards to cover duties that werethe result of staff vacancies and sickness. We were also toldthat on occasions staff were moved wards to provide coverfor staffing shortages, for example due to sickness at shortnotice. Staff considered this sometimes placed pressure onthem. The matron told us that the hospital continuedrecruiting nurses to fill vacancies.


Good –––


Green, amber and red staffing levels were set for each ward.Risk management actions had been agreed when staffinglevels fell to amber or red. We saw that amber and redstaffing levels were discussed at the twice daily bedmanagement meeting and action taken to address therisks. This at times included closing medical wards. Welooked at staff rotas for some of the medical areas andfound that shifts had been referred to agencies and bankstaff for cover and ward based staff also worked additionalhours to cover the shifts. This was confirmed by the trustwide NHS staff survey for 2012/2013 which identified that73% of staff worked extra hours. The trust had carried outreviews of acuity and dependency of patients to determinesafe staffing levels in April, October and December 2013.

A system was in place to alert all ward based staff topatients who were at risk from inadequate nutrition by theuse of red trays to present their meals on. Staff we spokewith had different interpretations of the use of red trays andsome suggested they indicated the person requiredassistance with feeding while others considered they werea reminder to prompt them to monitor the person moreclosely. The information contained in the handover sheets,regarding the use of red trays, was not included inindividual patient’s care plan documentation. Thisindicated the system to safeguard patients from insufficientnutrition was not consistently followed.

On admission to the hospital, either through theemergency admissions unit or directly to the ward,assessments were carried out to identify the care andtreatment risks and requirements of each patient. Fullwritten records of the assessment in the medical recordswere completed by the medical staff.

Care plans had not consistently been completed. Staff,particularly agency and bank staff new to the ward, did nothave detailed information to guide and direct them on howto meet patients care and treatment needs. Two staff wespoke with were not aware of patients care plans andreferred to the progress notes as the care records. Staff toldus they would refer to these daily progress notes whichwere recorded by medical and nursing staff. This meantthat patients could not be assured that records wouldinform staff how to manage risks to their health andwelfare.

Handovers between shifts did not always correspond withcare plans and staff understanding of patients’ care. Careand treatment that was agreed and delivered were not

always recorded so that a written record was available toall parties to ensure continuity of care. One patient wasreceiving oxygen but their medication record was not clearand their care plan did not reference this. The handoversheet which one member of staff held stated the patientrequired oxygen. The nurse and doctor we spoke with werenot aware that this was part of their treatment. Wheredieticians required nutritional intake to be monitored wefound that fluid and food charts had not always beencompleted. There were several blood sugar monitoringrecords in use which increased the potential of these notbeing completed accurately to inform clinicians’ treatmentdecisions. Staff could describe the personal care providedto patients. However, mouth care, washing and dressing,mobility and continence care plans were not seen forpeople who could not direct staff. The matron told us that aworking party had been set up to review ward paperwork toensure that it provided sufficient information for plannedcare and treatment to be delivered effectively.

Staff had received information and training to ensure thatpatients were protected from abuse. Information wasavailable for patients, their representatives and the staff onhow to report and respond to abuse. Patients who lackedthe mental capacity to make a decision were supported inline with the principles of the Mental Capacity Act 2005(MCA). Staff received training in the safeguarding ofvulnerable adults, MCA and Deprivation of LibertySafeguards (DOLS). Staff understood how these principlesapplied to their role. We saw examples of meetings thathad been held to make best interests decisions for patientsregarding some of their care and treatment when they didnot had the mental capacity to make such decisionsthemselves.

Anticipation and planningIn planning the safer staffing levels for medical wards thedivision took into account the past trend of staff sicknessand high turnover of trained nurses. By anticipating this riskthey ensured that a staffing level was agreed that couldmaintain safety even when these risks occurred. The NHSstaff survey for 2012 – 2013 identified that 73% of staffworked extra hours to cover gaps in the agreed staffinglevels. The hospital told us that a process of recruitment ofnursing staff was ongoing to provide a higher number ofavailable staff across the wards in order to meet the needsof patients.


Good –––


The medical wards had contingency plans in place torespond to winter pressures as well as emergencies andmajor incidences. Staff were familiar with the emergencyplans. One ward had six beds closed to admissions due toinsufficient staffing numbers. Though this meant a reducednumber of medical beds were available, patients could beassured that action would be taken to reduce the numberof medical beds if the hospital judged nursing staffnumbers were not sufficient to provided safe care. Whenmedical wards were closed bed capacity was created insurgery wards or at John Radcliffe hospital so that medicalpatients could continue receiving care.

Are medical care services effective?(for example, treatment is effective)

Good –––

Using evidence-based guidanceThe hospital had systems in place to ensure that themedical directorate was kept informed of relevantlegislation, guidelines and quality standards. Staff knewhow to access the hospital’s intranet system and where tofind information relating to national guidelines. Staff wereaware of National institute for Health and Care Excellence(NICE) guidelines relevant to the medical division and thenursing care delivered to patients on the ward they workedon.

Practitioners were available to provided specialist input inline with good practice guidelines. Staff on the medicalwards referred patients to specialist diabetes nurses.Records showed that patients with diabetes had been seenby the diabetic nurse who was based at the ChurchillHospital. Staff were positive in their comments about thisservice and the response they received when referringpatients. Tissue viability nurses were based elsewhere inthe trust and ward staff involved these nurses whensupport was required when managing pressure ulcers.

Systems were in place to ensure that patients nutritionaland hydration needs were met. Patients were weighed andscreened for malnutrition using the malnutrition universalscreening tool (MUST) on admission and weekly.

Performance, monitoring and improvement ofoutcomesRecords showed that one patient saw the diabetic nursefive days after being referred by ward staff and another hadbeen reviewed seven days before. It was not clear fromrecords how often patients were to be reviewed by thediabetes nurse and how ward staff were to implement theirrecommendations. We spoke with the diabetes lead whotold us that an integrated care pathway for in patients withdiabetes was still being formalised.

In the trust diabetes affects 14.7% of adult inpatients(compared to a national prevalence of 15.3%). They told usthat the care for inpatients with diabetes requiredimprovement following incidents of poor diabetes care,one of these took place at the Churchill. Diabetes risksummits were held in October and December 2013 toaddress these concerns. The diabetes quality group wouldbe responsible for the monitoring and delivery of the“Think Glucose” project to improve the quality of care. Itwould be chaired by the deputy medical director and startimplementation by March 2014. Actions included abusiness case to bring diabetes inpatient specialist nursesnumbers in line with the national average as well as earlyand comprehensive standardised assessments. Trainingwas also being delivered to ensure that inpatient diabetestreatment protocols were implemented effectively andconsistently in line with national guidance.

Staff, equipment and facilitiesStudent nurses were placed at the hospital and we heardthey felt well supported by the ward staff. The hospitalensured each student had a named mentor who workedwith and supported them during their placement. Wespoke to two student nurses who were working alongsidetheir mentor that day. Both told us they felt well supported,both by their mentors and the wider team.

Newly employed staff were provided with inductiontraining to familiarise them with the trust, the hospital, andtheir ward base. We spoke with a newly recruited memberof staff who was positive about their induction and thesupport received while on the ward. Staff also spokepositively of the support received and time spent in asupernumerary capacity on return from prolonged breakssuch as those due to maternity leave.

Staff were provided with core mandatory training andfurther training relating to the medical speciality theyworked within. Records provided to us showed 82%


Good –––


compliance with the trust’s statutory training. The loweststaff group for compliance with training was reflected asthe medical division. We heard comments from staff thatthe levels of vacancies at the hospital made accessingtraining harder as it was not possible on some shifts toleave their clinical areas. An electronic training system hadbeen introduced to enable staff to complete training online.

Multidisciplinary working and supportStaff worked together as part of a multidisciplinary team tomeet the varying levels of health, social and psychologicalneeds of patients. Patients and staff were not always clearwhat the agreed response time for specialist interventionswas. Most patients told us that they had received care andtreatment from the multidisciplinary team promptly andeffectively.

Are medical care services caring?

Good –––

Compassion, dignity and empathyDuring our inspection we observed staff talking withpatients on the wards in a warm, friendly andcompassionate manner. Care was explained in a clear andeffective way and the patient consent sought prior tocarrying out any care or treatment.

Curtains were drawn around beds when care was given.Patients had access to call bells and during our inspectionthey were answered promptly. Two patients we spoke withtold us that at busy times they might have to wait for theirbells to be answered. Patients confirmed their privacy anddignity were respected and were positive about the carethey had received and the staff who delivered that care.

Involvement in care and decision-makingThe medical and nursing daily records provided evidenceof the involvement of the patient and their families, whenappropriate, in discussions and decisions about their careand treatment.

Patients told us they had been provided with informationregarding their care and treatment and were able to makedecisions about their care. They had been given sufficientinformation in making difficult decisions and felt theirpreferences and choices made were and would berespected. We saw records which showed how decisions

regarding the patients’ care and treatment had beenreached and by who had been involved in the decisions.This had included the patient and their relatives. Thisensured all members of staff who were involved in the careof the patient had access to the information about theirplanned care and treatment. Records showed a relative ofone patient with complex care needs had been included indiscussions in the planned care pathway and their viewsrespected.

We received positive comments from one patient regardingthe multidisciplinary team working particularly regardingtheir experiences of pharmacy. We reviewed the process toenable patients to be involved in administering theirmedication. The procedures for this varied from ward toward. We found the option was not routinely offered topatients but if they asked they would be permitted toself-administer some medication like inhalers orsubcutaneous insulin. We saw one patient wasself-administering their medicines. A risk assessment hadbeen completed, in conjunction with and signed by thepatient, nurse and pharmacist. A review of the patient’smedicines administration record showed thatadministration was checked and confirmed as having beenself-administered.

Trust and communicationInformation leaflets about a variety of medical conditionsand treatment options were available to patients andrelatives to support them with their care and treatment. Wedid not see, but were told, information could be providedin a format to suit individuals. For example in a differentlanguage, large print, Braille or audio.

We followed the pathway of four patients through thehospital from their admission to the wards. Most patientswe spoke with were satisfied and confident in the care andtreatment they had received. Where patients had expresseddissatisfaction we were able to see from their records thatthey could be reassured that action that had been taken byappropriate staff to address their concerns.

Emotional supportRelatives and other visitors were welcomed to the ward bythe staff to see the patients who were supported to stay incontact with family and friends. Visiting times were detailedon the wards, although we were told by both staff andpatient’s that these times were flexible and relatives ofelderly patients were welcome to spend long periods withpatients.


Good –––


Patients were supported with spiritual needs by the trustsChaplains. Information was available regarding the NHSsupport for different faiths.

Are medical care services responsive topeople’s needs?(for example, to feedback?)

Good –––

Meeting people’s needsThe hospital took the needs of the community intoconsideration when planning and designing services. Dayservices had been developed to provide additional servicesto patients. We spoke with staff who worked in the dayservices department and were told patients were able toattend clinics to ensure their specific treatment and careneeds were met. This included assessments for patientswho required long term oxygen therapy and those whoneeded intravenous medication administered. Thisresource enabled patients to receive the appropriatetreatment without having to stay in hospital overnight.

There were co-ordinated pathways of care agreed withpartners to meet patients’ needs. The trust was part of theOxfordshire dementia development and implementationboard and the dementia steering group led on improvingcare of patients with dementia. The medical wards weremaking improvements to better care for patients withdementia. Staff confirmed that training in dementia carewas being delivered to ensure that they understood thejoint working arrangements. The medical wards had adementia champion that kept staff updated of any changesin the dementia pathway. Staff were aware that thehospital agreed to routinely undertake memory screeningof patients over the age of 75 to ensure the identificationand referral of patients with dementia.

Some patients with chronic illnesses, like cystic fibrosis(CF), were treated repeatedly on the respiratory ward. Therooms on the respiratory ward had en-suite bathrooms.These facilities enabled staff to meet the needs of patientswho had to attend the ward regularly with comfort andconvenience.

The medical wards we visited during our inspection aimedto provide patients with single-sex accommodation.However, at busy times when beds were limited wards had

to accommodate mixed sex accommodation if it wasclinically justified. Clear protocols were in place to ensurepatients privacy and dignity would be respected at thesetimes.

For patients whose first language was not English someinformation, for example how to make a complaint, wasavailable on the wards. There was also access to aninterpreter service either by the provision of an interpreteror through a telephone service. These included Polish,Cantonese, Mandarin, Urdu, Bengali, Arabic and Punjabiinterpreters which were reflective of the local population.Staff gave examples of when this had been used. We sawthe staff had supported one patient by ensuring importantconversations and discussions took place in the presenceof their relative to ensure full understanding as they hadlimited English.

Vulnerable patients and capacityThe hospital was sensitive to the support patients, whowere in vulnerable circumstances, might require to accessservices. Arrangements were in place to support those whodid not speak English and might need additional assistanceand adjustments to enhance communication while inhospital. We saw that telephone and face-to-faceinterpreters were available. A text phone service wasavailable to support deaf, hard of hearing and speechimpaired patients to make appointments. Patient transportcould be arranged for patients with disabilities. Wheelchairaccess was provided across the hospital.

Access to servicesThe hospital anticipated that there would be a higherdemand for medical beds during the winter. Beds insurgical wards were available to ensure that medicalpatients could still be treated if all the medical wards werefull. During our inspection we found ten medical patientswho had been admitted to the surgical wards due to a lackof available medical beds on their admission. Senior staffheld a bed management meeting daily which we attended.During this meeting all medical patients cared for insurgery wards were discussed. Plans were agreed formoving these patients to an appropriate medical ward asbeds became available. Surgical staff we spoke with told usthey ensured that they could meet the needs of medicalpatients before agreeing their admission to the surgerywards. If they felt that they lacked the specialist skillsrequired to provide safe care to an acutely ill medicalpatient this patient would be admitted to a specialist


Good –––


medical ward or transferred to the John Radcliffe Hospital.Medical patients were assigned to a named consultantresponsible for their care from admission. This meant ifmedical patients were admitted to other specialist wardsthey could be reassured that they would receiveappropriate clinical input. Surgical staff confirmed thatmedical staff attended the ward to carry out ward roundsand were available on the hospital bleep system at othertimes.

The trust had made arrangements to ensure patients hadaccess to out-of-hours pharmacy to supply any additionalmedications required. This service was provided from theJohn Radcliffe hospital once the pharmacy was closed atChurchill hospital. However, we found on occasions therewere delays in obtaining medication for patients. Anelectronic system was being introduced by the trust toimprove the processing of out-of-hours medicine.

Leaving hospitalSeveral patients on the medical wards were ready to bedischarged. Staff and patients told us that there had beendelays in patients leaving the hospital for a variety ofreasons. Staff explained that delays in discharge werefrequently due to patients waiting for community careservices. One patient told us ‘‘I cannot go home andcontinue with the treatment because I am out of area anddon’t have any support staff to assist with treatment whereI live. ’’ Two other patients told us that they had not beentold when they were likely to be discharged.

Staff told us that patients could wait a long time for theirmedication on the day they were discharged. Theyexplained that prescriptions for take home medicationwere not always written by the doctor and processed bythe pharmacy in a timely manner.

The matron told us that the hospital was working withstakeholders to deliver the discharge improvementprogramme to improve the internal and external dischargearrangements. This programme included actions toimprove the processing of medication for discharge.Discharge planners were being recruited on medical wardsresponsible for coordinating patients’ discharge. Theywould plan patients’ discharge from admission, ensuringall relevant information was shared with social services andliaised with care agencies and arranged transport. A weeklymulti-agency discharge meeting took place. During thismeeting all the patients reviewed by the DischargePathways team were monitored to ensure that appropriate

arrangements were in place to meet patients’ needsfollowing discharge. The hospital audits out-of-hoursdischarges, and overnight discharges remain low at 0.6% ofpatients.

Patients and carers had been involved in designing the newpatient leaflets for discharge. We saw that several leafletswere available to patients providing information about howto plan for the discharge process, transport andinformation about medicines.

Learning from experiences, concerns andcomplaintsThe medical wards captured and responded to patientfeedback. This included results from the Friends and Familytest, complaints and comments, Patient Advice and LiaisonService (PALS), Healthwatch Oxfordshire, National InpatientSurvey, Patient Led Assessments of the Care Environment(PLACE) and Patients Stories. Churchill hospital hadreceived the trust’s lowest score for food in the 2013 PLACEassessment. We were told the food provision had beenreviewed and patients we spoke with expressedsatisfaction with the choice and tastiness of food. Theacting divisional head of nursing and governance told usthat patients and relatives primarily raised concerns aboutcommunication, not receiving appropriate assistance anddischarge on the medical wards. Actions were in place toaddress these concerns and to gain a better understandingof how concerns could be addressed swiftly on the wards.

Patient feedback was reviewed at monthly medical divisionmeetings. Two Patient Stories relating to diabetes carewere presented at Trust Board and Quality Committeemeetings in February 2014, one of which related toChurchill Hospital. Lessons learnt from these patients’experiences were captured in an action plan whichincluded training for staff in adhering to diabetes protocolsand supporting patients to manage their anxiety.

Leaflets and signs were in the hospital to inform patientshow to make a complaint, access PALS and complete theFriends and Family test. Patients could access theIndependent Complaints Advocacy Service (ICAS) if theyrequired support with making a complaint.


Good –––


Are medical care services well-led?

Good –––

Vision, strategy and risksThe trust told us they were committed to ‘‘DeliveringCompassionate Excellence’’. They described the cultureand values underpinning the hospital as ‘‘learning, respect,delivery, excellence, compassion and improvement.’’During discussions we had with staff it was evident theyshared the trust’s values. They were proud of their hospitaland were committed to providing good care to theirpatients.

We spoke with staff from all levels in the medical divisionincluding the clinical director for acute medicine andrehabilitation. Systems were in place to ensure that riskswere identified and understood on all levels. The concernsregarding recruitment and discharge shared by staff on thewards were the same as those captured at division andboard level.

Governance arrangementsDuring our discussion with senior managers, ward staff andclinical specialists it was clear that monitoring andgovernance arrangements were in place in the division.Sisters and the matron we spoke with were clear what theirresponsibilities were in analysing and reporting on qualityinformation. We saw information on noticeboards thatprovided feedback to staff on the outcomes of audits andgovernance meetings. The matron told us how they hadcontributed to the recent safe staffing assessment as wellas compiled incident information to be submitted to thedivision’s monthly quality meeting.

The hospital monitored risks to the delivery of care througha risk register. Several risks relating to the physicalenvironment in parts of the Churchill Hospital had beenidentified and actions plans were in place to reduce therisks. Actions that had already been taken included fixingthe roof for the John Warin ward which should reduce riskof leaks. The action plan noted that concerns ‘‘have beenescalated to divisional level and are currently beingescalated to executive level’’.

Leadership and cultureStaff told us they felt supported by their immediatemanagers and were able to raise concerns with them and

felt they would be listened to. Many staff had leadresponsibilities for enhancing patient pathways on themedical wards. This included dementia, falls, consent andsafeguarding champions. Senior staff told us that the shifthandover time had been reduced. This time was often usedfor team meetings and the matron told us that alternativetime for team meetings was being sought.

The ward sisters from the Churchill Hospital rotatedattendance at the John Radcliffe Hospital sisters meetingsbetween them. This ensured management and leadershipissues were identified from the wider trust and cascaded tosenior staff at the Churchill Hospital. The sistersdevelopment programme was available to ward sisters todevelop their leadership capabilities to solve problems,innovate and manage change was available to staff.

Human Resources’ practices promoted a culture ofcompassion towards patients. The hospital used valuesbased interviewing to ensure that staff were recruited thatprioritised high quality and compassionate care. Thematron explained to us how this had been implemented inthe recent recruitment of Spanish nurses to medical wards.They also told us how the hospital’s values had beenincorporated in the clinical support workers academy aswell as the competency bridging course for foreign workers.

Patient experiences, staff involvement andengagementPatient views and experiences were sought by the hospital,by the provision of quality questionnaires, and fed back tostaff on the wards. We saw patients had access toinformation about the ward or department as this wasdisplayed in the corridors. This demonstrated openness bythe hospital to engage with patients and listen to theirfeedback to improve the services provided.

Information from the NHS Choices website gave theChurchill hospital 4.5 stars out of 5 overall with high scoringfor cleanliness, staff co-operation, dignity and respect andinvolvement in decision making. They scored 4 stars out of5 for same sex accommodation. The monthly qualityreports showed that the wards had been effective inincreasing the completion of the Friends and Family test inboth the Geoffrey Harris and John Warin wards thisenabled them to understand the experience of a largergroup of patients.

Posters were observed in the hospital inviting staff to sharetheir opinions regarding the service provided through the


Good –––


initiative known as ‘listening into action’ which was runningin the hospital. This focuses on three areas of change;quality and safety, the patient experience and workingtogether. The hospital continued to embed the ListeningInto Action (LiA) project. This empowered staff to findinnovative solutions to problems they identified. Themedical wards were identifying their LiA champions.

Not all staff had been provided with annual appraisals orsupervision. Staff were confident they could approach andtalk to senior managers if they needed to. Ward managerswere able to provide the up to date figures for staffappraisals on their ward and we saw these had improvedsince the findings of the NHS staff survey for 2012.

Learning, improvement, innovation andsustainabilityThe hospital took part in national clinical audits whereeligible to do so and outcomes from these audits wereprovided to staff.

During 2012 the trust launched a five year vision for theorganisation, which included the Churchill hospital, andwhich aimed to deliver continuous quality improvementwith a focus on three key areas for 2013/14: patient safety,patient experience and clinical effectiveness. This showedthe commitment of the hospital to engage with improvingservices to patients.


Good –––


Safe Good –––





Information about the serviceThe Churchill Hospital provided surgical care andtreatment for people on five inpatient wards which includethe Oxford Colorectal Centre, Oxford Upper GastrointestinalCentre, Urology Ward and the Jane Ashley Centre. There isalso a day surgery unit, a theatre direct admissions unit, acomplex of 10 operating theatres with a recovery and anovernight recovery unit.

We visited three surgical wards, two operating theatres,and recovery areas and talked with 12 patients and 15 staffincluding nurses, doctors, consultants, therapists andsupport staff. We observed care and treatment and lookedat care records. We received information from our listeningevents, focus groups, interviews and comment cards. Weused this information to inform and direct the focus of ourinspection. Before our inspection, we reviewedperformance information from, and about, the trust andthe hospital.

Summary of findingsThere was consensus among patients, carers and staffthat staff were dedicated and provided compassionate,empathetic care. Processes were followed to reduce anyrisks to patients undergoing surgical treatment.

Staff made use of the language line facility andinterpreters to ensure patients had a goodunderstanding of their treatment and were able to makeinformed decisions.

Staff had a good understanding of the Mental CapacityAct 2005 which meant patients received the appropriatesupport to be able to make their own decision, or whererequired decisions involving appropriate people weremade in the best interest of the patient.

Generally, there was sufficient equipment available tomeet the needs of patents. However, concerns wereexpressed about access to radiology for some patients.This meant that patients had to undergo radiographyprocedures on the day of their planned surgery, ratherhaving all investigations completed prior to the day ofplaned surgery.

There was evidence that learning from incidentsoccurred and that changes were being made inresponse to findings from quality auditing processes.

We saw good evidence of team working at ward anddepartmental level.

Surgery

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Are surgery services safe?

Good –––

Safety and performanceSafety in theatres at the Churchill Hospital was good. Therewere 206 patient safety incidents (trust wide) reported bythe trust’s surgical services to the National Reporting andLearning System (NRLS) between July 2012 and July 2013,accounting for 34% of all incidents reported across allspecialities. Of these, 192 were graded moderate, 11 abuse,two severe and one death.

Between December 2012 and November 2013, 35 seriousincidents were reported in surgical services trust-wide.Twenty were in ward areas, four in operating theatres andone in a day case theatre. Of these, two were categorised asnever events.

Doctor Foster hospital mortality data showed that mortalityrates in surgery at this hospital were not a cause forconcern. The incidence of pressure ulcers, infections,venous thromboembolism (VTE) and falls on surgical wardswas also within the expected range.

The safety and wellbeing of patient’s undergoing surgicalprocedures was protected through following best practiceguidance. The Oxford University Hospitals Trust used theWorld Health Organization’s (WHO) surgical safety checklistin operating theatres. The WHO checklist is a systemdesigned to prevent avoidable errors. We saw good use ofthe checklist in the two operating theatres where weobserved practice. The theatre staff we spoke with said thechecklist was done well. Weekly and three monthlyauditing of the WHO checks lists meant that processes toensure patient safety were being monitored.

Assessments for the risks of pressure ulcer development,venous thrombosis and risks of falls were completed andrelevant action was taken to reduce identified risks. Thisincluded the use of pressure relieving equipment andprescribed anti embolic stockings both on the surgicalwards and in the theatre complex.

The Oxford University Hospitals Trust had a children’s andadult's safeguarding policy. Training about safeguarding

adults and children was part of the mandatory annualtraining that all staff were expected to complete. Staff knewabout the policy and were confident about reportingsafeguarding concerns.

Learning and improvementThe hospital learned from incidents and took action toavoid re occurrence. Theatre staff gave examples aboutchanges in practices made as a response to incidents thathad occurred. This included incidents that occurred locallyat the Churchill Hospital and incidents such as never eventsreported across the trust. There was a process for informingall staff about reported incidents and action that needed tobe taken to reduce the risk of similar incidents occurring.

On the surgical wards, staff knew about the process toreport incidents. We were told that staff received promptfeedback about any incidents they reported.

The trust used a process of peer reviewing to assess thequality of the service being provided. The divisional nursefor surgery and oncology discussed the shortfalls identifiedat their recent peer review (November 2013) and theactions that had been taken to make the necessaryimprovements.

Systems, processes and practicesThe wards had systems and practices to follow to ensurepatients received consistent and safe care. Care plans wereused effectively to inform staff about the care and supporteach patient needed which included identifying risks andimplementing action to reduce the impact of the risk. Careplans for patients identified at risk of pressure ulcerdevelopment detailed the types of pressure relieving aidsthat needed to be used. We saw that these were beingused.

A “track and trigger” system was being used on the surgicalwards. The aim of this tool was to ensure the earlydetection of any deterioration in a patient’s condition sothat timely intervention could take place.

There were sufficient hand washing facilities on the surgicalwards and in the operating theatre complex. Anti-bacterialgels were situated at the entrance and exit to all wards andthe theatre complex and on the end of patient’s beds.Patients told us that staff washed their hands betweencontact with each patient, and we saw them do this.

Surgery

Good –––


Patient education meant they were aware of theimportance of hand washing. This was confirmed inconversations we had with patients. This practice reducedthe risk of cross infection.

The divisional nurse for surgery and oncology informed usthat it had been identified during the peer review qualityassurance process that resuscitation equipment on thewards was not being checked daily. We looked at checkingrecords for the resuscitation equipment and otheremergency equipment on two of the surgical wards. Theyhad been checked daily to ensure all equipment was indate and in working order.

There was sufficient equipment to meet the needs of thesurgical patients. We saw that equipment for theprocedures and monitoring of patients in the operatingtheatres was readily available. Staff told us that therequired equipment for procedures was always available.On the wards there was sufficient equipment available tomonitor and support patients. We saw monitoringequipment, pressure relieving equipment, moving andhandling and other clinical equipment available in suitablenumbers. Procedures were in place to ensure allequipment was routinely serviced and checked. We sawrecords to evidence this was occurring.

Monitoring safety and responding to riskThere was a clinical governance system to monitor qualityand safety. This operated at team level, reporting upwardsto directorate, divisional and trust level. Each directorateand division maintained a risk register and produced amonthly quality report. Risk registers were also discussedand reviewed monthly.

There were staff in sufficient numbers and skill mix toprovide safe and effective care. The trust had completed arecent review to determine the correct level ofestablishment and skill mix for staff on in patient wards. Wesaw on each ward a chart that identified the ideal level ofstaffing for each shift, adequate level of staffing and detailsabout what level of staffing would mean patients were atrisk of poor and unsafe care. Staff said they used thisguidance to request extra staff if for any reason staffnumbers indicated patients were at risks of poor or unsafecare. Patients told us there were always sufficient numbersof staff on duty to support them with their needs. Patientsand visitors commented that call bells were answeredquickly.

To ensure continuity of care for patients the surgery andoncology division had employed ‘long term’ agency nurseswhile recruitment to permanent positions was completed.

A permanent night team for the operating theatres hadbeen employed, supported by a second team of staff beingon call at night. This was in response to demand for theatreactivity at night due to emergency cases and organtransplantation.

Staff were effective at supporting people in making theirown decisions and choices. Staff had a good workingknowledge of the Mental Capacity Act 2005. Training aboutthe Mental Capacity Act 2005 was included in themandatory safeguarding training for all staff. Staffdemonstrated in discussion that they understood theapplication of the Mental Capacity Act 2005.

Are surgery services effective?(for example, treatment is effective)

Good –––

Using evidence-based guidanceEvidenced based guidance was being followed to delivereffective care. The pre admission nurses followed theNational Institute for Health and Care Excellence (NICE)guidance for pre admissions when assessing patients. TheWHO check list was used in the operating theatre complexto ensure patient safety. On the transplant ward relevantguidance for transplant procedures and check lists werefollowed.

Performance, monitoring and improvement ofoutcomesWe found that generally patient record keeping was good.On the wards records were good, with a few gaps, butoverall well completed. We saw that monitoring of patientshealth and wellbeing was completed at the intervals asstated in their track and trigger charts or their plans of care.We saw that patients care was reviewed daily and their careplans altered according to their needs and wellbeing.

Staff, equipment and facilitiesStaff we met said they felt encouraged within their divisionto learn and improve. Staff were appraised and givenopportunities for personal development. Nursing staff onwards had specific link roles, such as palliative care and

Surgery

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infection control. They were enabled to attend specifictraining and meetings with regard to their link roles.Appraisals were being held with staff in accordance withguidelines and they were up-to-date for all available staff.

Patients were supported to meet their nutrition andhydration needs. Nutritional needs were assessed onadmission and plans developed to support people to meettheir nutritional needs. Inpatient wards had protected mealtimes, so patients were not disturbed when having theirmeals. Patients told us that the variety of food wassatisfactory. Patients on the transplant ward told us theyhad access to a dietician to support them with their dietaryneeds. One patient said, "I get a dietician, they get me quitegood food. Special diets are accounted for.” A secondpatient on another ward said the dietetic department hadsupported them to gain weight so they would be fit forsurgery.

Patient’s pain was generally well managed. There wereprocesses followed for monitoring patient’s pain. However,one patient on the colorectal ward had experienced delaysat night in receiving their pain relieving medication whichhad caused them distress. This, the patient told us, was aone-off situation and after they had made the wardmanager aware of their experience, they were confidentthat action had been taken to reduce the risk of a similaroccurrence happening. Other patients said that staffprovided them with pain relieving medicines when theyneeded it. One patient said, “pain management isexcellent.” A second patient told us that the medical stafftalked to them a lot about pain management. A thirdpatient said they saw the pain specialist every day.”

Support from the radiology department was not effective atensuring all patients had the scans required for surgery. Wewere told that the radiology department could not keep upwith requested scans for oncology patients. This meantthat some patients had to have scans on the day of surgeryrather than have all investigations completed prior tosurgery.

Multidisciplinary working and supportRegular multidisciplinary meetings took place on thewards. These were attended by the medical, nursing andtherapy staff together with the patient and/or theirrepresentatives when appropriate. Detailed records of theoutcomes of these meetings were recorded in detail in thepatient’s records.

Patients spoke about the involvement of the whole team intheir care. This meant the involvement of specialist nurses,physiotherapists and occupation therapists, medical andnursing staff. Patients commented that communicationacross all teams was good. One patient told us “Themedical team have been marvellous and they haveobviously been talking to each other.” A second patient toldus there was good communication between the twodifferent specialists involved in their care.

Are surgery services caring?

Good –––

Compassion, dignity and empathyPatients’ experience of care was good. All patients wespoke with told us staff were caring and kind. We observedgood care on all wards, in all interactions. Patientcomments included “I feel very safe. I feel very confidentabout all people around me. It’s a very very nice place to beif you are ill”, “I feel as though I am being looked after bypeople who really know what they are doing and aregenuinely concerned about my wellbeing. They are veryhappy I am getting better” and “This department isoutstanding…better care all round, even the tea lady isfun…nothing is too much trouble for the staff.”

Patient’s privacy and dignity was respected. We saw thatcurtains were drawn around patient’s beds when personalcare was provided. Ward accommodation was segregatedso men and women were afforded privacy and dignity. Onsome wards accommodation was all in single rooms, whichaided the promotion of privacy and dignity. Patients told usthey could request whether to have a male or femalemember of staff providing their personal care and thosearrangements would be made with the staff complementto comply with their request.

Patients had access to call bells which they could use tocall for assistance. We saw that these were in easy reach.Patients told us staff responded promptly when they calledfor help.

We saw the results from friends and family tests weredisplayed in each of the inpatient ward areas. This showeda high level of satisfaction with the service provided.

Surgery

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Involvement in care and decision makingPatients felt they were appropriately involved with theircare. All patients we spoke with told us that fullexplanations were given to them by medical staff andnursing staff about their proposed treatment in mannerthat they could understand. They said consent procedureshad been done well. We were told by a patient, “EverythingI have ever had done has been well explained, I havealways been kept in the loop.” They told us “I was notpushed to sign consent, I get the last say.”

Patients for planned admissions had appointments withthe pre admission nurse prior to their admission. Literatureabout their operation/treatment and what to expect whenthey came into hospital was provided both in the writtenform and verbally at this appointment. Most patients toldus they felt fully informed about their admission andtreatment.

Patients were supported to manage their own medicines.Assessments were completed of patient’s capacity tomanage their own medicines. Patients told us that theywere assessed by nursing staff before being deemedcompetent to manage their own medicines. Records welooked at evidence this process took place.

Trust and communicationPatients said staff were friendly, open, and sensitive to theirneeds. Patients said they were encouraged to askquestions if they did not understand the treatment beingprovided. Staff were able to access a telephone languagelink service to support patient’s whose first language wasnot English. If needed interpreters were employed to assistwith communication. Staff gave examples where they hadused interpreters during the treatment of patients toensure they understood and were able to make informedchoices about their care and treatment.

Information about the trust and the hospital was availableon the trust’s website. This included easy read informationfor people who had difficulties understating written word,leaflets about various conditions and what to expect whenundergoing surgery. The website could be translated into anumber of different languages.

Emotional supportPatients and relatives told us they received the supportthey needed to cope emotionally with their treatment and

hospital stay. There was a chaplaincy service available forpeople of all religious denominations. Some patients spokepositively about the support they had received bothemotionally and practically from specialist nurses.

Are surgery services responsive topeople’s needs?(for example, to feedback?)

Good –––

Meeting people’s needsPatient needs were being met. Patients told us they werehappy with their care and said their needs were being metand that all staff were responsive to their needs. They said“nothing was too much trouble.” Most people who hadused their call bells when they needed help said, staffalways responded quickly.

Vulnerable patients and capacityPatients admitted to the surgical wards were assessed toprotect their rights and meet their needs. Staff said patientswho were not able to make their own decisions due to alack of mental capacity would have care and treatmentgiven in their best interests. The family or an advocate forthe patient was involved in any decisions along with thepatient’s medical team. This process was confirmed in aconversation we had with one patient who had been veryunwell and decisions about treatment had to be made ontheir behalf. They told us that the decision that had beenmade was the decision they would have made had theybeen well enough to make that decision. This showed thatthe team making that decision had a good insight into thewishes and beliefs of the patient and were therefore able tomake the appropriate decision on behalf of the patient.

Staff had experience of supporting people with a learningdisability. Staff knew about the ‘hospital passport’ whichwas a document people with a learning disability usuallybrought with them to tell health and social care providersmore about them. The document said what the personliked, did not like and how to treat them. Staff said thecarers for the patient were closely involved with their careand staff took advice from them to help support thepatient.

Surgery

Good –––


Access to servicesAccess to services was good. Patients told us that therewere no delays with their admission to hospital. Staff toldus cancellations to surgery lists were primarily due topatients having not received admission letters.

Leaving hospitalMost of the patients we spoke with had been giveninformation about their discharge from hospital and theyknew when they were expected to be discharged. If neededthey had been assessed by physiotherapists andoccupational therapists about their home circumstancesand the support available to them. Arrangements wereconfirmed about how they would get home.

Staff told us that patients’ discharge was planned as soonas they were admitted. We saw that an estimated dischargedate was recorded in their notes. They told us that patientswere given information about their surgical proceduresbefore their admission and this included information aboutafter care. This was reinforced on their discharge.

However, one of the 14 patients we spoke with expressedconcerns with their previous discharges. They felt they hadnot received sufficient information to enable them tomanage their illnesses and condition on discharge, Thisthey believed had resulted in re-admission to the ward.However, they said that they now felt they had sufficientinformation to manage independently when they weredischarged from hospital.

Learning from experiences, concerns andcomplaintsThe divisional nurse had told us that the peer reviewprocess had identified a lack of patient information on thewards. Most patients had received this information duringpre-assessment processes. We were told that as a result ofthat finding processes were being implemented to makesure the information patients had received prior toadmission was understood before they were discharged.Other patients spoke how good the discharge process wasand that if they had any concerns they were given thenumber of the ward to ring for advice and support.

Patients told us they would feel comfortable aboutcomplaining to staff if something was not right and theywere confident that their concerns would be taken

seriously. People knew how to complain. Most people toldus they would talk to staff and some were aware of thehospital’s Patient Advice and Liaison Service (PALS), whichwas publicised on the wards and on the trust’s website.

The wards we visited had received few complaints. As aresult, most staff we asked could not identify any themeswithin the complaints received.

The hospital routinely captured feedback using the friendsand family test. Staff told us that results were regularlydiscussed at team meetings.

Are surgery services well-led?

Good –––

Vision, strategy and risksThere was a clear trust vision and a set of values, whichwere patient focused. Many staff did not know what thevision and values were but portrayed similar values andpassion and motivation to provide excellent patient care.Senior management and other staff we spoke with wereclear about the trust mission and values.

Governance arrangementsThere was a clear governance structure with reporting linesfrom departments through directorates and divisions,ultimately to the trust board. Quality and performancewere reviewed with the peer review process and anyconcerns or problems identified were discussed andstrategies developed to address them. There was a systemfor learning from incidents.

Leadership and cultureStaff said they were well supported. There was a mixture ofnew staff and others with many years of experience. Newstaff said they had been made to feel very welcome andthere was a planned induction programme to follow.

The staff said there were good working relationshipsbetween the medical staff, nurses and other professionals.They felt supported in their roles and were comfortable toraise their concerns at local level. Staff told us they weresatisfied with the local management arrangements, andfrom information on the trust’s internal website and emailcommunications were aware of the leadership of theorganisation and trust board.

Surgery

Good –––


Patient experiences, staff involvement andengagementPatients’ views and experiences were a key driver for howservices were provided. There was information displayed inwards showing how the ward was performing and what thefriends and family test results were telling them. Staff saidthey felt involved and informed about patient safety andexperience. The divisions that each ward was aligned toheld regular staff meetings where all staff could participate.Staff on wards said that attended or were represented athandover meetings when shifts were changing.

Learning, improvement, innovation andsustainabilityThe surgical and oncology division had recently introducednew nursing roles with the aim of improving outcomes forpatients using the service. This included the introduction ofenhanced recovery nurses and nurse practitioners. Linkshad been made with local higher education establishmentsto support training for operating department practitioners.

Surgery

Good –––


Safe Good –––





Information about the serviceThe critical care unit at Churchill Hospital has eight beds.There were arrangements to provide 24 critical care bedsbetween the adult intensive care units at John Radcliffehospital and Churchill Hospital. This allowed for flexibilityof how many beds were available at each hospital butwould not exceed a collective bed number of 24. At theChurchill Hospital the beds organised as six bays and twoside rooms.

Critical care covers both intensive care and highdependency care with level 2 being high dependency andlevel 3 being intensive care beds. The critical caredepartment at Churchill Hospital had level 2 and level 3beds and which were considered as critical care and nothigh dependency beds.

We visited once during the day and talked with one patient,this low number was due to the difficulties incommunicating with some critically ill patients. We spokewith 14 members of staff. These included nursing staff,consultants, junior doctors, and management of the units.Before our inspection, we reviewed performanceinformation from, and about, the trust and listened tocomments from people at our listening events. We alsoreviewed data from the Intensive Care National Audit &Research Centre (ICNARC) for April 2012 to March 2013.

Summary of findingsAlert systems were in place to escalate patients withdeteriorating health from the wards to intensive care.However, most patients at Churchill on the critical careunit were planned as surgical post-operative care. Notrauma or accident and emergency admissions camedirectly to this unit. A patient follow up system was inplace to ensure patients leaving critical care andreturning to the wards were well supported. There wasconsultant cover on all of the departments 24 hourseach day.

Patients received safe care. Clinical outcomes weremonitored and demonstrated good outcomes forpatients. Care provided was effective with amultidisciplinary approach taken and good standards offacilities to meet patient’s needs. While staff recruitmentand retention was recognised by the trust as an issue,the levels and skills of staff on a day-to-day basis wereconsistently managed by using staff from John RadcliffeHospital.

Patients told us the kindness and care of staff was good.The unit was responsive to the needs of the patient andlearned from safety events or incidents. Thedepartments were well led and demonstrated a positiveleadership and open culture to enable staff to feelinvolved in changes.

Intensive/critical care

Good –––


Are intensive/critical services safe?

Good –––

Safety and performanceMonitoring took place to promote patient safety. Each thecritical care units in the trust used a standardised record formeasuring their performance and so all safety data wascomparable. This increased the learning available to eachcritical care unit. Saving lives data was collected and theaudit results were visible in the staff room. Safety auditsincluded a monthly check on infection controlassessments, falls, urinary tract infections and incidentsrelating to pressure damage. Churchill intensive unit hadnot had any falls or urinary tract infections in the mostrecent audit. The hospital trust contributed their data tothe Intensive Care National Audit and Research Centre(ICNARC) in order that they could be evaluated againstsimilar departments nationally. The results of this and allmonitoring was reviewed and discussed at divisionalmeetings each month. Monitoring of mortality includedcomparisons to other trusts. We saw that ICNARC data fromthe first two quarters of 2012/13 showed the ChurchillHospital Intensive Care Unit units had a StandardisedMortality Ratio (SMR) that lay comfortably on or below(better than) the mean value. Further data was alsomonitored monthly which related to the views of patientsand their relatives. The comments made by patients andrelatives were used when needed to change practice on theunits.

We saw that patient’s safety was considered and wellmanaged. The unit had security arrangements in place toensure the safety of patients on the ward and anybodyentering the ward was checked and when needed preparedbefore visiting their relatives. Patients who wereunconscious or unable to comment were protected frominappropriate people on the unit.

Learning and improvementStaff told us and records showed they learned fromuntoward events. All serious incidents were recordedthrough the incident reporting system and wereinvestigated and discussed at the divisional governancemeetings. Staff told us that they received feedback fromthose meetings and learning from all of the critical careunits was shared to develop and improve practice.

The unit had developed its own focus group which affordedstaff the opportunity to discuss the challenges of workingon the intensive care unit and about how to delivercompassionate care to families and carers.

Systems, processes and practicesSystems for patient records were managed safely. Nursesused an electronic system for care records and information.Medical and nursing staff told us this system was suitablefor purpose and secure access was maintained by staffusing passwords to access patient notes. The electronicrecords excluded do not attempt resuscitation records. Allelectronic stored information was backed-up and could betransferred into paper records in preparation for transfersto other wards when patients were discharged. Electronicprescribing systems had been implemented and medicinerecords could be reviewed by the unit pharmacist either onthe unit or remotely.

Infection control and hygiene was monitored and theresults made public on each unit. The trust’s infection ratesfor methicillin-resistant staphylococcus aureus (MRSA) laywithin a statistically acceptable range, taking into accountthe trust’s size and the national level of infections. Weobserved good hand hygiene taking place in all areas. Aninfection control lead nurse worked on the unit andundertook regular audits. The current hand hygiene audithad an overall score of 84% compliance. This was brokendown to doctors 82%, nurses 92% and visiting doctors 29%.Resulting learning from this meant that further trainingwould be planned for visiting doctors. An equipmentcleaning audit was done monthly and daily cleaningincluded bed areas. We observed that side rooms wereused when patients presented with any kind of potentialinfectious symptoms. While empty, a negative pressuresystem was used to ventilate those rooms to reduce spreadof airborne particles.

Medicines and equipment were safely stored. All medicinesand equipment was stored securely and were onlyaccessible by the staff on the unit. Stock medicines werechecked and good stock levels maintained. The storage ofequipment was well managed and all equipment needingcollection for repair was clearly marked.

Facilities in the intensive care unit were of a high standardand the unit had been purpose built. It was clean, spaciousand suitable for purpose. Staff told us that they hadsufficient equipment to meet the needs of the patients. All


Good –––


equipment was stored above floor height and systemswere seen for the repair/replacement of equipment.Equipment was standardised and made available acrossthe two hospital sites.

Accommodation was available on all of the units forrelatives to stay overnight. There was also a sitting roomavailable for staff to explain to relatives what washappening and a room available for the delivery of badnews.

Monitoring safety and responding to riskMonitoring systems were used to make improvements tosafety and work practice. Bed allocation meetings wereheld throughout the day. This allowed the opportunity fordiscussion about the need for intensive care beds or thetiming of discharges from intensive care to the wards. Thisenabled staff to communicate earlier with theatre staff toplan the theatre lists and promoted a more effective way ofworking. This was also an opportunity for staffing issues tobe raised and addressed if possible on site. Systems werein place to access extra staff if needed. There was access toa contingent workforce, most of whom had experience ofworking on the unit before.

The critical care departments recognised and understoodrisks. The managers for each critical care unit decided whatrisks were escalated to the service risk register and howthey were to be managed. Issues related to pressure sores,medicine errors and capacity of the unit were high areas ofidentified risk.

All deaths on the critical care units were reviewed to informand direct current practice. These were discussed by themedical teams to ensure learning from outcomes.

There was a surge escalation plan in place in preparationfor any emergency requiring critical care beds.

There were sufficient medical and nursing staff available onthe unit. Staffing levels followed national guidelines aboutcaring for critically ill patients. This meant that for a levelthree patient they received one-to-one care. For level twopatients they would share one nurse between two patients.This was because they had less critical care needs. Furtherstaff were also available to assist with tasks includingmoving and handling and transferring patients. The staffrotated between three hospitals and a system was in placewhereby staff rang a taped message each morning to findwhich unit they were working on that day. Staff told us thatthis system was not a problem to them.

Medical staff and consultant staff was available 24 hoursper day and seven day cover was provided at all times.There was one consultant and two junior doctors each dayand one consultant and one junior doctor overnight.Medical cover was rotated three to four weekly over theJohn Radcliffe and Churchill Hospital adult intensive careunits and all doctors were intensive care trained. Doctorsfelt well supported and had unlimited access to seniormedical staff. Medical staff told us that they found thehandovers of information to be well organised.

Patients who lacked the mental capacity to make adecision were supported to ensure that their best interestswere served by using the Mental Capacity Act andDeprivation of Liberty Safeguards. A checklist was availablefor staff to use to guide assessments of mental capacity. Forthose patients who lacked the capacity and temporaryability to make decisions, decisions were made by medicalstaff in their best interest. This was recorded to include therationale for the decision and who was involved includingfamily members/representatives or advocates for thepatient.

Anticipation and planningThere was not an outreach team available in the hospital tovisit and assess deteriorating patients with a view toadmission to the critical care beds. A system was in place toalert staff to the level of deterioration considered to be inneed of critical care. Staff told us that the “track andtrigger” tool to ensure early detection of any deterioration,monitoring in place on the wards was effective. There weresystems in place to review how this alert system wasundertaken and its level of success. Churchill Hospitaladmissions were mostly planned for post-surgery criticalcare.

As part of the discharge planning a follow up team was inplace available seven days per week. This altered to crosssite cover at the weekends. We spoke with the follow upnurse who advised that as part of discharge planning thisservice supported the patient and staff on the ward fortransfer.


Good –––


Are intensive/critical services effective?(for example, treatment is effective)

Good –––

Using evidence-based guidancePatient’s received care in line with national guidelines. Wesaw that the management of skin damage by pressure ormoisture damage was effective. The role of a unit-basedtissue viability nurse had been allocated and this nursevisited twice each week and ensured staff were kept up todate with new methods and equipment. Trolleys ofdressings were being implemented to enable staff toaccess the equipment they needed quickly and easily. Allgrade 2, 3, and 4 damage was recorded as a notification toinform the hospitals auditing process. These were alsodiscussed at clinical governance reviews to consider if thecurrent methods of management were effective. The tissueviability lead audited all pressure damage daily whichshowed a reduction in skin damage. In the previous monththe unit had only one reported incident of pressuredamage. Any learning outcomes were shared across all ofthe critical care units. However, it was noted that the highhealth risks of patients receiving critical care often meantthat pressure damage could not always be avoided.

Performance, monitoring and improvement ofoutcomesOutcomes for patients were good. The adult intensive caredepartment was equipped for up to eight patients with aflexible arrangement with John Radcliffe Hospital toaccommodate up to 24 patients between them. The trust’sbed occupancy average for July to September 2013 hadbeen higher than the England average and above therecommended rate of 85%.

We were told by staff that there was an issue with delayeddischarges and this had impacted on planned admissionsfollowing elective surgery. Information received showedthat in January 2014 two elective surgeries had beencancelled. However, for critical care beds, the trust’soccupancy rates have been lower than the Englandaverage for the period of September to November 2013

Mortality rates at Churchill Hospital had not been raised asan area of concern. The ICNARC data for the first quarter of2013 showed that there were a number of unplannedreadmissions within 48 hours. The number is higher than

would be considered the normal rate and had appeared tohave doubled in the past year. This may be related to thetype of patient admitted post-surgery or the lack of highdependency step down beds available to meet the needsof level 2 patients. Further information supplied to usshowed that in January 2014 two patients had beenreadmitted within 48 hours. Since August 2013 to date ninepatients had been readmitted. The unit manager told usthat any re-admission was reviewed to identify the reasonsfor the readmission as part of the governancearrangements. Any issues identified would be addressed.

The management of deep venous thrombosis wasrecorded electronically and staff reviewed equipment andmedication needed routinely to reduce the risks to patientsof thrombosis. A warning on the electronic recordingsystem reminded staff to complete this area or remindedthem if a review was due.

There were no reports of any hospital-acquired infectionssuch as MRSA or Clostridium difficile for the previousmonth to our inspection.

Staff, equipment and facilitiesThe trust continues a foundation training programme forall nursing staff to ensure sufficient training in critical care.This included competence assessment and observation ofcare being provided. An induction programme took placefor all new staff. These staff were extra to the plannednumber of staff to afford them time for learning. Furtherspecialist training packages were available to support staffand time was made for mandatory training to take place. Amentorship programme by band seven nurses providedfurther support to new and existing staff. There was acolour coded name badge system which allowed newstarters to be recognised by the broader team andtherefore supported more effectively. We were told that96.2% of Churchill staff had completed all mandatorytraining areas. These included, safe moving and handling,infection control and fire safety. Further training to developcompetencies were available to assist band five staffprepare for band six roles.

Multidisciplinary working and supportMultidisciplinary working takes place to support patientsacross other areas of the hospital.

We saw the input from therapists included physiotherapy, adietician and occupational therapy to promote the healthand welfare of patients. The unit had two dedicated


Good –––


physiotherapists each day with only one working at theweekend as most admissions were for elective surgery andthis did not take place at the weekend. We saw that theallocated dietician used to support the nutritional needs ofpatients had been cut back and was now available byreferral. The follow on team worked with ward staff tosupport critical care patients who had improved andmoved on to wards. The management of organ donationwas managed within the critical care unit. Organ donationstaff visited the unit twice weekly to ensure staff wereaware of the procedures to follow and the access to contactinformation for transplant

Are intensive/critical services caring?

Good –––

Compassion, dignity and empathyPatients and relatives spoke in the highest terms about thestaff and the care they had received. They said staff hadexplained to them at each stage what was happening andtreated them at all times with dignity and respect. Onepatient, who was a planned admission following surgery,felt totally prepared for the admission to the intensive careunit. The patient had been given a mobile telephone tomaintain contact with relatives and felt they had received“five-star care.”

The unit was a mixed sex area but curtains were providedto ensure the dignity of the patient. Each bed had 2.5m-wide unobstructed circulation space provided at thefoot of each bed space in line with HBN 04-02.This allowedfor the use of equipment and also enabled staff and familyto be able to discuss quietly and have a degree of privacy.

Involvement in care and decision makingPatients who were able to talk to us said they felt involvedin what was happening to them. Decisions were taken inthe best interest of patients. Consent was actively soughton all levels including consent to provide personal care andconsent to change position. Pre surgery consent wasreceived in a signed format. For planned post-surgeryadmissions the manager told us that patients were visitedand supported to understand what to expect on the unit. Atthe time of this inspection no patients needed a Do NotResuscitate decision made about them and as such wecould not see documents relating to this. Policies relatingto this issue were available on computer for staff to follow.

Staff explained what action would be taken should thepatient not be able to participate in the decision process.Recently a decision about resuscitation had taken placeand staff described time spent sitting and talking with thepeople concerned to gain an understanding of how thesituation should be managed.

Trust and communicationPatients and relatives had the opportunity to speakregularly with doctors and nurses about their care andtreatment. When patients stayed for a period of time on theunit staff took time to get to know the patient and theirrelatives. For those patients who had specialistcommunication needs, information about how best tocommunicate was obtained prior to admission to supportboth the patient and staff to communicate better. Staff toldus that recently following a particularly long admission staffdeveloped trust and friendship with relatives who latervisited the unit to see the staff and left a gift for staff toremember their relative. We observed staff sitting withpatients and chatting, taking time to talk then through theprocedures and discuss the day. We saw staff assisting apatient to sit out into a chair. This was done slowly with fullexplanations given to support the patient and staff stayedwith the patient to ensure they were safe and confident.

Emotional supportEmotional support was provided both during admissionand after discharge from the critical care units. Staff tooktime to explain procedures to patients and their relative totry and allay any anxieties and fears associated with anadmission to the unit. Prior to elective surgery staff wouldprepare the patient for admission to the unit withexplanations of what to expect. A room was available forthe delivery of bad news which enabled relatives to havetime and privacy to discuss news with doctors and nursingstaff.

A focus group of patients had been developed to discussissues that had arisen following discharge. Information wasavailable about life after intensive care and information forrelatives. Visiting at Churchill Hospital Intensive care unitwas open and a pleasant waiting room was available withfacilities for them to rest when visiting.

Are intensive/critical services responsiveto people’s needs?(for example, to feedback?)


Good –––


Good –––

Meeting people’s needsPatients said they felt well cared for. Meetings took placeearlier in the morning on the unit to assess each patientand decide if they would leave the unit that day. This alsoenabled the availability of beds to be assessed earlier. Thisinformation was then passed to the theatre department toinform the theatre list for patients who requiredpost-surgery critical care beds to establish if they wouldhave a bed or not. Those patients who had a tracheotomyin place were only considered for discharge early in eachweek to ensure sufficient medical cover was available.These patients were sometimes cared for a little longer onthe critical care unit while they waited for a bed on therespiratory ward. This was because they had specific andspecialist nursing needs, Delays of four hours or more totransfer did however take place and three patients haddelayed discharges in the last month. The ICNARC datashowed that delayed discharges were higher thanexpected. We were told by staff of some cancellations inelective surgery due to bed capacity not being availableand some delays in discharges. Information provided to usby the trust showed that no cancellations took place inDecember 2013. However, 27 cancellations took place inbetween August 2013 and January 2014.This informationwas recorded through a notification process to enable thisdata to be discussed at divisional governance meetings totry to establish the reasons for delay and how this could beavoided.

Once a patient was discharged to another ward the criticalcare unit had a follow up nurse from the critical care unitwho visited patients on the ward. This follow up took placeto ensure that the ward staff had the specialist support theyneeded and ensured a continuity of care for the improvingpatient. Initially patients were seen by the follow up nursewithin 24 hours and depending on their health needs maycontinue to be visited by the follow up nurse daily. Afterthat the follow up nurse would review and assess whatsupport the patients and nursing staff needed. Should apatient be transferred to John Radcliffe Hospital, the followup nurse would contact the follow up nurse at that locationand ensure a continuity of care.

Vulnerable patients and capacityFor those patients who had a carer at home, for examplepatients with a learning disability, carers were involved withtheir care and staff took advice from them to help supportthe patient to ensure a continuity of care and to meet thepatient’s needs.

Visits could take place by the hospital Chaplain to supportthe spiritual needs of patients, relatives and staff regardlessof their beliefs and a 24-hour on call service was provided.A place for prayer was also available for relatives andvisitors.

Access to servicesOver 1,200 critically ill adults were admitted to the twoadult intensive care units at John Radcliffe and ChurchillHospital per annum. Facilities were available for relatives/carers to be able to stay overnight. The accommodationwas pleasant and suitable for an overnight stay.Information available to relatives and carers informed themabout what to expect from each unit, information relatingto visiting times and facilities and how to raise a concern.

There were some links with the palliative care team for endof life support but this was not routine. Staff said that theyhad experience of transferring patients to the hospice forspecific palliative care.

Leaving hospitalPatients were discharged with appropriate information. Itwould be very rare for any patients to be discharged homefrom the critical care units. Patients who left the unit forother wards or hospitals had a paper record of theirelectronic notes produced to accompany them. Should itbe needed staff would go through the notes to explain anycritical care records being provided. Any issues arounddischarge would be raised with the staff team to promotelearning. The electronic systems in other parts of thehospital were not compatible with the electronic system onthe critical care units and so printed notes were provided.Should the patient be sent to another hospital, sufficientinformation was provided to inform the receiving hospital.Training in transferring patients had been provided to allstaff and so any inter hospital transfers would follow thehospital policy and equipment and transfer informationwould be recorded.

The hospital maintains a policy that no patients will betransferred between inpatient areas for non-clinicalreasons between 8pm and 8am. This included transfers


Good –––


from ward to ward and transfers to other health providersoutside of the trust. Staff told us that every effort was madeto adhere to this policy and a notification was made torecord when these transfers took place. All transfers wereplanned to take place as early as possible in the day toenable handover communication to be effective.Re-admissions to critical care units took place as aresponse to deteriorating critical conditions. The level ofre-admission for each unit was measured against otherunits across the country using ICNARC data. The data forthe early part of 2013 would indicate an increase inunplanned readmissions within 48 hours.

Learning from experiences, concerns andcomplaintsEach critical care department captured patient feedback.This included results from the Friends and Family test,complaints and comments. Each unit also requestedinformation via their own questionnaires. We saw that allinformation received from the questionnaires had beenreviewed and when areas for change had been identified,planned actions to make changes was posted on noticeboards. Feedback provided to the unit was used to changepractice. This included information about noise, the needfor clocks and waiting times for relatives. Staff told us thatthey received feedback from notifications, complaints andpatient experience feedback. No complaints had beenreceived about the unit at the time of our inspection.

Are intensive/critical services well-led?

Good –––

Vision, strategy and risksStaff were clear about the trust vision for the future. Theyexplained they had been involved in the development ofthe vision and felt involved in the strategy and future of thetrust. These values included learning, respect, compassionand improvement. Some staff felt the executive board weremore visible than others. Some staff did not know whotheir divisional lead was or who to contact with any boardlevel questions. Staff were confident to contact the unitmanager or matron to raise any issues or make suggestionson their behalf.

Governance arrangementsThe critical care departments monitored the quality of itsservice. There were good arrangements for monitoring the

service at local level and the results of the audits aroundcare and practices were good. The critical care leads fromeach department met monthly. This was an opportunity todiscuss any issues and feedback from complaints, reviewnotifications or areas of concern. The divisional governancemeetings were attended by managers from each unit. Riskswere also discussed at this time and review of critical areaswhich may need escalating to the trust risk register. Wereviewed the trust risk register and saw that risks aroundstaffing were recorded, with an action plan in place toaddress the shortfall.

Leadership and cultureStaff told us that they were proud of the units they workedon and had felt supported as new members of staff. Theytold us they enjoyed working across the three sites ofChurchill and Horton Hospitals and John RadcliffeHospitals and had no concerns about the unit. The seniorcare team of band six and seven nurses provided acontinuity of leadership at the Churchill Hospital.

Staff teams from each critical care department werewell-led. Staff told us that they had “great leadership” and asupportive management team. Senior staff and managerswere visible on the unit daily. Staff told us they felt able toapproach the unit manager or matron with any issues orquestions and that their views would be listened to andfeedback given.

Board walk around took place and staff felt able toapproach board members at this time to raise anyquestions or views. Management staff told us they feltlistened to an involved in decisions which changed theservice.

Patient experiences, staff involvement andengagementStaff felt part of the hospital and wider trust. Complaintswere managed via Patient Advice and Liaison Service(PALS) and staff told us that there were very few complaintsbut they were included and informed of broaderorganisational complaints. We observed a staff memberexplaining to a relative the complaints process and alsomaking an effort to ensure that the concerns raised werealso managed locally within the hospital.

Learning, improvement, innovation andsustainabilityStaff were appraised and given some time for personaldevelopment. Staff appraisals were undertaken to support


Good –––


and develop staff practice. Where areas of support wereneeded this was being implemented. This included theopportunity for staff to discuss with a psychologist whenthere had been challenging or distressing incidents atwork. Staff we met said they felt encouraged to continuewith learning and development of their practice. All policiesand procedures were available on the electronic system onthe unit to support and guide staff and ongoing learningwas provided weekly on the unit.

Staff also told us that a recent peer review exercise hadtaken place. This had involved visiting each unit andreviewing the standards and practices taking place. Stafftold us that this had been a valuable learning experienceand one staff member felt this should be done more oftento continue with the learning opportunities it presented.


Good –––


Safe Good –––





Information about the serviceEnd of life care was not provided in a single setting, butintegrated in wards and departments across the hospital.The hospital had a palliative care team providing supportto staff caring for patients at the end of their life or needingpalliative care. The hospital also provided 24-hourpalliative care advice to patients nursing staff and doctorsby phone or by visits to patients if clinically indicated.

Sir Michael Sobell House Hospice offers expert care andsupport to those suffering with advanced or progressive lifelimiting illness. Multidisciplinary care and support isprovided in the 18-bedded inpatient unit, day centre,patient's homes, and in the acute Oxford RadcliffeHospitals.

We spoke to two patients on in haematology and oncologywards and the relatives of a patient in Sobell House. Wespoke with five ward staff across Churchill Hospital andSobell House.

Summary of findingsPatients received effective and sensitive end of life care.Patients told us they felt safe and their needs were metby skilled staff. Patients knew the reasons for theiradmissions and had made decisions about where tohave their end of life care. Patients’ pain was wellmanaged by the clinical staff and they did not have towait for their medicines. Staff respected patients’ rightsand, in particular, their privacy and dignity.

Palliative patients were able to make decisions aboutthe medical procedures to be followed in the event of acardiopulmonary arrest. If the decision was not toresuscitate in the event of a cardiopulmonary arrest, thedecision was recorded and professionals made aware ofthe decision.

Patients were cared for with compassion by staff whoknew how to care for patients at the end of their life.Hospital staff attended palliative care training and wereable to attend study days on end of life care to updatetheir knowledge.

Palliative patients had access to a centralised helplinewhich offered advice and referrals for admissions. End oflife patients arriving on the emergency medical unitwere assessed and transferred to the most appropriateward to meet their care and treatment needs.

Systems were in place to provide sensitive care topatients on end of life pathways and their families.Haematology palliative patients were able to receivetreatment as day patients in a recently opened

End of life care

Good –––


ambulatory room enabling them to remain longer intheir own homes. A four-bed flat was available on sitefor families who wanted to be close to their relativeduring their end of life pathway.

Are end of life care services safe?

Good –––

Safety and performanceThe hospital had responded to changes in guidance for thedelivery of care. The trust had phased out the LiverpoolCare Pathway (LCP) in line with recommendations from theIndependent Review Panel. Advance care planning formsdeveloped with the Oxfordshire End of Life ReferenceGroup followed on from previous end of life strategies. Theforms were designed to capture information and thewishes of the patients. Essential information included theprofessionals involved; their diagnosis; if a do not attemptcardiopulmonary resuscitation (DNACPR) form was inplace; and the patient’s wishes for their future.

Learning and improvementThe hospital learned from incidents and was continuouslylearning. The Quality Account reports 2012/13 for the truststated incident reporting had improved with theintroduction of the electronic reporting system across thetrust. This system had allowed for “real-time assessmentsof clinical incidents” which gave the trust an opportunity toidentify trends and improve patient safety.

Systems, processes and practicesPatients felt safe with the staff who delivered their care andtreatment. The patients we spoke with told us they felt safewith the staff. One patient said: “I feel completely safe withthe staff.” The family of a patient in Sobell House told ustheir relative was safe and the staff ensured they were painwas controlled.

The care needs of patients were assessed. The nursingassessment, incorporating the activities of daily living carerecords form had replaced the LCP monitoring tools. Thenurses we spoke with told us an individualised approachwas now used for all the patients on the ward. For example,patients received support with their physical, emotionaland cognitive health. One ward nurse told us the formswere good but there was limited space to evaluate patient’sneeds. We looked at the notes for two patients at the endof their life. Risk assessments were completed for movingand handling, malnutrition universal screening tools(MUST) and pressure ulcer care. Where risks were identified

End of life care

Good –––


further action was taken to prevent deterioration andmaintain the patient’s comfort. The notes showed staffreceived guidance on how to meet the needs of patients onan end of life care pathway.

Policies were in place to ensure staff followed correctprocedures for patients considered not suitable forresuscitation in the event of a cardiopulmonary arrest. The“do not attempt cardiopulmonary resuscitation (DNACPR)and child and young person’s advance care plan (CYPACP)”policy explained the hospital’s procedure. The policyrequired staff with direct patient contact to discussadvanced decisions with the patient and/or their carers in atimely manner. The roles and responsibilities of staff weredetailed in the policy and directed the patient’s consultantto complete do not resuscitate forms for the patient if thiswas appropriate. Consultants had to then document thedecision to ensure the staff and other externalprofessionals involved with the patient knew not toresuscitate the patient in the event of cardiac or respiratoryarrest.

Monitoring safety and responding to riskThe hospital responded to identified risks. The safety ofpatients in relation to the delivery of medicines wasanother key area identified by the trust for improvement in2012/13. Audits were undertaken to assess the levels of risk.Staff ensured medicine rooms were locked and only thosestaff with responsibilities for the administration medicineshad access to the medicine room. Action plans weredevised from the audit undertaken by the pharmacist withthe ward sister. A ward sister showed us the actions takenfrom the recommendations made by the pharmacistfollowing the audit carried out in January 2014. Themedication room was relocated to a quieter area of theward, and better security systems were introduced.

Staff knew the principles of the Mental Capacity Act 2005.Ward staff knew where there was doubt of the patient’scapacity to make decisions, mental capacity assessmentshad to be undertaken. One nurse gave us an example ofwhen a patient’s capacity was assessed to ensure they wereable to make decisions about their discharge beforepackages of care were put in place. Another nurse told usthe multidisciplinary team which included the consultantmade “best interest” decisions on behalf of patientsassessed as lacking capacity to make decisions.

Anticipation and planningCodes for resuscitation orders differed from ward to ward.The use of different codes for the same outcome could beconfusing to staff. Codes were used to inform staff of themedical procedures to be followed for specific patients inthe event of a patient having a cardiopulmonary arrest. Wenoted from the handover sheets (summaries of patientscare and treatment for staff coming on duty) that eachward had different codes for resuscitation orders whichmay have been confusing to staff not routinely deployed tothe same wards.

Are end of life care services effective?(for example, treatment is effective)

Good –––

Using evidence-based guidancePain was well managed. One patient told us their painmedicine was administered through a syringe pump tomaintain a consistent level of pain relief. One member ofstaff told us there was support from the pain managementteam and they offered advice on prescribing medicines tocontrol patient’s pain.

Staff ensured patients were free from pain in betweenscheduled times of other medicines. Staff from SobellHouse told us patients were prescribed with medicineswhich could be used when required (also known as PRNmedicines) for symptom control and for pain relief. Theyhad pain medicines through a syringe pump. We were tolddiscussions had taken place with consultants to be moreproactive in prescribing medicines early to prevent delaysin managing patient’s pain.

Performance, monitoring and improvement ofoutcomesWhere decisions had been made around resuscitation, theforms confirming this were completed. A patient confirmedthey had signed the form and another said they wereinvolved in the decisions about their care and treatment.The ward staff told us patients were assessed on admissionand decisions were made about their care pathways. Therewere conversations with the consultant and ward staffabout patient’s treatment. The consultant and nursing stafffrom the palliative care team met with the patient andfamily to discuss the best supportive care.

End of life care

Good –––


Staff, equipment and facilitiesThe hospital ensured the staff had the right skill mix.Patients knew the reasons for their admission and the careand treatment they were to receive. One patient told usthey were seen by a healthcare specialist for their care andsaid: “The expertise is amazing. I have been seen by topconsultants and by nurses.” The patient’s notes we lookedat showed a multidisciplinary team was involved in thecare of the patient. Staff from the palliative care teamrecorded the advice given on symptom control and wardnurses documented when treatment changed tosupportive care.

There were safe handovers between shifts. Ward staff wereupdated on the patient’s condition when they came onduty. They told us there was an overlap of staff forhandovers where all patients were discussed. There werepre-populated handover sheets given to staff when theycame on duty. These sheets included a summary of apatient’s history, diagnosis and essential information.Essential information included patients identified forfast-track discharge, those who did not wish to beresuscitated, and patients receiving palliative care.

Multidisciplinary working and supportPatients received care and treatment from amultidisciplinary team. One patient told us specialistpalliative care nurses visited and they focused on aspectsof their medical condition. A ward nurse told us there werestrong links with staff from palliative care services. Theytold us the team were quick to respond and offered directsupport to patients and staff. Palliative care staff helpedpatients plan where they wanted to be. The notes we readshowed patients had access to health care professionals.We saw when staff from the palliative care team visited theydocumented the advice they offered. For example, advicearound pain management. Staff from Sobell House told usthere were social workers and physiotherapists working atthe hospice. This was to ensure patients had access tosocial care support for them and their families, and forequipment they may need as in patients or in the event oftheir discharge.

Are end of life care services caring?

Good –––

Compassion, dignity and empathyPatients were well cared for. The patients we spoke withmade positive comments about their end of life care andtheir families agreed with the patient’s views. One patientsaid: “the care here is second to none” and explained howtreatment provided was to help with their end of life care.Another patient told us their privacy and dignity wasrespected. They said it was excellent. Ward staff told uswhere possible patients on end of life care were transferredto a side room to respect the patient’s dignity. We were toldvisiting times were more flexible for patients at the end oftheir life. One relative told us: “The staff care about me too.”Another family told us: “They have been fantastic from themoment we got here.”

Involvement in care and decision makingPatients were involved in the decisions about their careand treatment. One patient told us their consultant hadtold them when their treatment was no longer curative. Wewere told they were given the choice to move to thehospice, but had decided to remain on the oncology ward.Another patient told us they were involved along with theirfamily in the decisions about their care.

Trust and communicationThe staff understood when providing end of life careconsideration must be given to patient’s diversity andequalities. A member of staff gave us an example to showpatients religious beliefs were respected. We were told: “Wefelt strongly we needed to respect the patient’s faith andwe did their personal care correctly.”

Patients were able to maintain links with family and friends.Patients receiving end of life care told us visiting times weremore relaxed. Ward nurses told us the arrangements theymade for families to spend as much time as possible withtheir relative. For example on one ward there was a sofabed for families to use when they wanted to stay overnightto be with their relative.

End of life care

Good –––


Emotional supportSupport was available to patients. Sobell House staff toldus there was counselling support from the chaplaincy;patients had access to psychiatry and there was externalbereavement counselling for children and young people.Ward staff told us the Chaplin was available at all times

Are end of life care services responsive topeople’s needs?(for example, to feedback?)

Good –––

Meeting people’s needsPatients were cared for by staff who knew about end of lifecare and who had been trained to provide end of life care.One member of staff told us they had end of life trainingduring their induction and attended study days to maintaintheir knowledge and skills.

The staff at Sobell House told us there was a strongmultidisciplinary team. The multidisciplinary teamdocumented their information in the patient’s notes whichensured the social and health care professional involvedwere aware of the care and treatment patients werereceiving. We were told there was an admission bookletwhich gave a good history of the patient’s palliative carehistory.

Vulnerable patients and capacityPatients received care that supported family arrangements,culture and beliefs. The staff we spoke with knew how toaccess support for patients. A ward nurse gave us anexample where social care support was provided for apatient at the end of their life who chose to have their carein the community. Another ward nurse told us they hadaccessed websites to support a patient with their finances.

Access to servicesThere was a single point of access for patients. Patients onend of life care arriving at Churchill Hospital on anunplanned basis were assessed at “triage” to determine thepriority for treatment based on their medical condition. Atriage nurse told us there the multidisciplinary team wereable to refer patients for care to wards, other hospitals andhospices. Sobell House staff told us referrals to the hospicefor care and treatment came through triage for patients onunplanned admissions.

The identification of patient’s reaching their end of life wasan area for improvement by the trust. The staffs told usdecisions to determine when patients were reaching theend of their life were made by the consultants and themultidisciplinary team. The patients we spoke with werepart of the decision about their care and treatment.

Specialist teams were involved in the care of patients at theend of their life and receiving palliative care. We were toldthere were good working relationships with the palliativecare team. We were told they were quick to respond. Theyvisited the patient and developed a plan to support thepatient’s wishes.

Leaving hospitalFast-track discharge procedures were available for patientson an end of life care pathway. Ward staff knew there was afast-track discharge process and said patients were able tohave their end of life care at home, in the hospital, at Sobellhospice or in the community. Ward staff co-ordinatedfast-track discharges. A discharge check list had to becompleted to ensure community teams had essentialinformation to deliver care to patients at the end of theirlife. Sobell House staff told us fast-track discharges wereavailable to patients wishing to have end of life care athome.

Learning from experiences, concerns andcomplaintsPatients knew there was a hospital complaints procedure.The family of a relative in Sobell House said ward stafflistened to their concerns and passed their feedback to themanager of the ward. We saw information on The PatientAdvice and Liaison Service (PALS) on display for patients tocontact in the event they wanted to discuss concerns.

Are end of life care services well-led?

Good –––

Vision, strategy and risksThe hospital had a strategy for end of life care. The OxfordUniversity Hospitals Trust Quality Account report 2012/13featured patients experience as a key objective specificallycare of the dying.

Governance arrangementsThe standards of care evaluated in the National Care of theDying Audit Hospital (NCDAH) Round 4 2013/ 2014 were

End of life care

Good –––


based on the End of Life Care Strategy (DH, 2008) andreflect National Policy Guidance. Compassionate care ofthe dying patient was an essential aim for NHS Trusts, andcommissioners wanted evidence of the provisions ofquality care. The audit report for the National Clinical Auditwas expected in 2014.

The Oxford University Hospital Trust reports on mortalityrates as part of their clinical excellence. The Health andSocial Care Information Centre (HSCIC) werecommissioned to gather mortality rates across trusts inEngland. The Oxford University Hospitals stated in theirquality account report that their mortality rates wereapproximately 10% higher because of their inpatientpalliative services.

Leadership and cultureThe staff were proud about the way end of life care wasprovided to palliative patients. One member of staff said:“We are very good at providing end of life care.” A memberof staff at Sobell House told us: “We are good at accessingsupport.”

Patient experiences, staff involvement andengagementPatients were able to refer themselves to the specialistpalliative care team and were able to speak with thedoctors responsible for their care. Patients were involved indiscussions about their discharge and treatment plans andwere informed about the progress of their illness.Discussions with patients and/or their relatives around DoNot Attempt Resuscitation (DNAR) decisions were recordedin patient’s records.

Written information for patients described the services andsupport available and gave contact information for theorganisations concerned.

Learning, improvement, innovation andsustainabilityServices were in place to provide sensitive care to patientson end of life and their families. Haematology palliativepatients were able to receive treatment as day patients in arecently opened ambulatory room enabling them toremain longer in their own homes. A four-bed flat wasavailable on site for families who wanted to be close totheir relative during their end of life pathway.

End of life care

Good –––


Safe Good –––

Effective Not sufficient evidence to rate




Information about the serviceThe level of outpatient activity provided at the ChurchillHospital 2012/13 was 191,124 which accounted for 25.3% ofthe total trust-wide activity. The hospital is a centre forcancer services and specialities including renal andtransplant, oncology, dermatology, haemophilia, infectiousdiseases, chest medicine, medical genetics and palliativecare. The outpatients services are located in separate areaswithin the specialities provided. We visited oncology/haematology outpatients, respiratory outpatients and therespiratory day service. We spoke with ten patients andfour staff.

Summary of findingsPatients received safe and effective care. Someoutpatient and day services were in an old part of thehospital not well suited to the delivery of modern dayhealthcare. We saw that this was recorded in the riskregister and that temporary actions had been taken tomitigate the risk. Identified remedial work had not beenundertaken and genetics and cystic fibrosis servicesaffected had not been relocated as planned. We werenot able to establish when this would be completed.The clinics we visited were well led and patients told usthat the care was excellent

Outpatients

Good –––


Are outpatients services safe?

Good –––

Safety and performanceWe were unable to get a full view of the staffing becauseoutpatients clinics were spread throughout the hospital ineach department. We visited two clinics and spoke withfour staff. In the oncology/haematology outpatients amember of staff told us there were no trained staff to runthe clinic but this would change. There were specialist andresearch nurses working in the clinic that provided patientsupport. There were 21 clinic rooms and 21 consultantswhere 300 patients were seen daily. We observed a patientqueue that stretched into the corridor and meant the firedoor in the corridor was constantly open. Frail patients andpatients on crutches had to stand and wait to be bookedinto the clinic. There was insufficient room to ensurepatients’ health and safety at all times.

In respiratory outpatients there were several staff runningthe clinic. We briefly spoke to a nurse at the end of amorning clinic. The clinic was very busy in the afternoonand we were unable to speak to a trained nurse. Therewere three consultants in the clinic. The administrationstaff told us they had the equipment they needed includingresuscitation equipment. The staff felt that theenvironment was safe but old.

A review of staffing and nursing roles for outpatients startedin January 2014. The Churchill outpatient project plan,dated 21 January 2014, highlighted that Band five nurseinterviews were taking place on 27 January 2014 to ensuresufficient staff were available. We were unaware of theoutcome.

Learning and improvementWe were unable to get a full view of the staffing becauseoutpatients clinics were spread throughout the hospital ineach department. We visited two clinics and spoke withfour staff. In the oncology/haematology outpatients amember of staff told us there were no trained staff to runthe clinic but this would change. There were specialist andresearch nurses working in the clinic that provided patientsupport. There were 21 clinic rooms and 21 consultantswhere 300 patients were seen daily. We observed a patientqueue that stretched into the corridor and meant the fire

door in the corridor was constantly open. Frail patients andpatients on crutches had to stand and wait to be bookedinto the clinic. There was insufficient room to ensurepatients’ health and safety at all times.

In respiratory outpatients there were several staff runningthe clinic. We briefly spoke to a nurse at the end of amorning clinic. The clinic was very busy in the afternoonand we were unable to speak to a trained nurse. Therewere three consultants in the clinic. The administrationstaff told us they had the equipment they needed includingresuscitation equipment. The staff felt that theenvironment was safe but old.

A review of staffing and nursing roles for outpatients startedin January 2014. The Churchill outpatient project plan,dated 21 January 2014, highlighted that Band five nurseinterviews were taking place on 27 January 2014 to ensuresufficient staff were available. We were unaware of theoutcome.

Systems, processes and practicesWe spoke with ten patients and two were concerned theyhad waited a long time in the oncology clinic. Two patientstold us that car parking was a big problem and they hadtaken more than forty minutes to park. One patient hadbeen given a parking permit because they had frequentappointments. A patient told us their GP had not received ahospital discharge letter, so no outpatient referral wasmade. An urgent referral to oncology was made on 6December 2013 and an appointment was given for 26February 2014. The patient had not received an apologyand was told by their GP to go to A&E. The patient told usthey would be writing to the Patient Advice and LiaisonService (PALS) about the delay as they had lost two stone inweight while they waited.

Monitoring safety and responding to riskSome outpatients and day services were in the old part ofthe hospital. We spoke to a member of staff in therespiratory day service and they told us the environmentwas not fit for purpose. There was no piped air and onlyemergency suction was available. The areas were used forassessment and gym facilities for patients with cysticfibrosis, sleep studies, patients with chronic obstructivepulmonary disease (COPD) and outpatients. Corridors thatlinked areas were extremely dilapidated and cold. Stafffollowing the ‘bare below the elbows’ rule feltuncomfortable, and morale was poor as a result. Staff toldus there was a plan to move services from there two years

Outpatients

Good –––


before our inspection. A comment from a patient surveycarried out six months before our inspection for the dayunit said, “building in need of a refurb”. There were plansindicated in the response to the survey for sleep studypatients to be moved on 28 February 2014.

The risk report said “infrastructure which does not meetmodern healthcare needs and cleaning standards.Windows fall out of the frames, radiators burst and powerfailures are common occurrences”. The trust had put sometemporary measures in place, but the risk remained fordamage to equipment, records, and patients’ perception ofsub-standard care. We were unable to visit geneticsoutpatients where concerns had been raised with us as itwas not operational that day. However, we visited therespiratory day care services, which were next door togenetics outpatients and saw that the environment waspoor. There were rusting windows in the corridor, the areahad an unpleasant odour, and there were visible electricson the floor near a reception desk.

Staff said they were unsure as to when the physicalenvironment would be improved. We saw that this wasrecorded in the risk register and that temporary actionshad been taken to mitigate the risks. Heaters and fans wereavailable to support staff with extreme temperatures. At thetime of our inspection we identified remedial work had notbeen undertaken and all services affected had not beenrelocated. We were not able to establish when this wouldbe completed.

Anticipation and planningThe outpatient services were under review to ensure clinicshave the capacity to meet increasing demand forappointments. The trust had employed a company tocollate audits from outpatient clinics to plan theimprovements required and improve the patientexperience.

Are outpatients services effective?(for example, treatment is effective)Not sufficient evidence to rate

Using evidence-based guidanceCare and treatment was delivered in line with evidencedbased guidance. The trust participated in national clinical

audits, reviews of services, benchmarking and clinicalservice accreditation. A patient told us they thought theconsultants they had seen were the best in their field andthey were confident about their care and progress

Performance, monitoring and improvement ofoutcomesThe trust participated in national clinical audits, reviews ofservices, benchmarking and clinical service accreditation.Customer care workshops attended by 50 clinic nurses andadministration staff took place in January 2014 as aresponse to patients surveys and complaints. There wererecurring themes from patients that were discussed atoutpatient steering group meetings. The themes related tolate running and delays in clinics (including blood tests);lack of or poor information about the running of clinics ordelays; the availability of car parking and no timetable inbus shelter. It was reported that the themes were beingaddressed. We spoke with ten patients and two wereconcerned they had waited a long time in the oncologyclinic.

Staff, equipment and facilitiesWe were informed that an additional senior band six nursewas to be recruited to help run outpatients and provide thenecessary support for both staff and patients.

Multidisciplinary working and supportWe observed good multidisciplinary working in oneoutpatients department we visited. Specialist nurses andresearch nurses supported patients. Patients told us theyhad their MRI scans and x-rays done quickly within a weekand the care was excellent.

Are outpatients services caring?

Good –––

Compassion, dignity and empathyPatients told us they felt safe and that the staff were politeand approachable. We observed that staff treated patientswith compassion and dignity while they received their careand treatment. Consultations took place in private roomsand staff did not discuss patients in public places.

Involvement in care and decision makingPatients told us they were involved in their care and sowere their relatives. The patients were able to giveinformed consent to treatment and nurses had provided

Outpatients

Good –––


any additional information to help them. A patient told usthat the nurses would print information for them from thecomputer if they need it. Patients told us there wassufficient time to discuss options with the consultant.

Trust and communicationWe observed that staff greeted patients with respect andwarmth. The majority of patients told us the experienceand care was very good. A patient in the oncologydepartment told us that they would get immediate carewithout going to their GP or the A&E department.

Emotional supportPatients received support from specialist oncology nursesand research staff. Patients told us that the staff culture wasgood and they said the environment in oncology was lovelyand welcoming. A patient in respiratory medicine had beenwell supported by the staff on many occasions and hadconfidence in the care and treatment at the hospital.

Are outpatients services responsive topeople’s needs?(for example, to feedback?)

Good –––

Meeting people’s needsThe provider actively engaged and worked with localcommissioners of service, the local authority, otherproviders, GP’s, patients and those close to them toco-ordinate and integrate pathways of care that meet thehealth needs of the local population.

Patients’ needs were assessed at each appointment andcare planned and delivered to meet their needs. A patientand their relative in respiratory medicine were able toaccess the department from a nearby car park at the backof the hospital near the clinic. They used a hospitalwheelchair to ensure the patient was comfortable. Therewas a calm atmosphere in the two outpatients we lookedat.

Some clinics were in the old part of the hospital and werenot as spacious as the new clinics. There was little space towalk around in one clinic we visited but staff supportedpatients and there was a calm atmosphere.

Vulnerable patients and capacityStaff were trained to protect vulnerable adults and childrenwho may or may not have the mental capacity to makedecisions. Safeguarding training was mandatorythroughout the trust and staff had access to the trustsafeguarding policies and procedures for adults andchildren. We did not test staff knowledge but patients toldus that they felt safe and that staff were kind andapproachable.

Access to servicesWaiting time guidelines and performance issues weremonitored by the trust and there had been some breachesof national waiting times for appointments. Theadministration staff told us that the choose and booksystem for appointments worked well for most patients.Most of the ten patients we spoke with were able to bookan appointment easily. There were some patients that hadto wait a long time in the clinic when consultants were busyand arrived late. We spoke with ten patients and two wereconcerned they had waited a long time in the oncologyclinic. Two patients told us that car parking was a bigproblem and they had taken more than forty minutes topark. One patient had been given a parking permit becausethey had frequent appointments.

Leaving hospitalPatients’ needs and wishes were taken into account so thatthey left the department with appropriate information.

Learning from experiences, concerns andcomplaintsPatients told us they knew how to make a complaint if theywere not satisfied with their care. There were leaflets in thehospital that described how to make a complaint and howto feedback their views. From August to December 2013, 38(61%) of patients indicated they would be “extremely likely”to recommend the service to a friend. There was nomention in the patient information leaflet about contactingthe Health Service Ombudsmen for further support ifrequired by patients. Patients we spoke with told us thecare was excellent or good. There were concerns raisedabout car parking, waiting times in the clinic and twopatients had not been referred in a timely manner. Actionwas being taken with regard to these matters as the trustwere reviewing the way that outpatients was organised andmanaged to ensure that the capacity within outpatientclinics met the increased demand. The trust were havingdiscussions with the county council about car parking.

Outpatients

Good –––


Are outpatients services well-led?

Good –––

Vision, strategy and risksQuality drives the trusts strategy and the board is aware ofpotential and actual risks to quality. There was a monthlyoutpatients steering group meeting where best practicewas shared and risks were identified. At the meeting inJanuary 2014 there had been discussion about patientquestionnaires and providing a regular view of alloutpatient departments on a specific week each quarter.One outpatient clinic had already used a monthlyquestionnaire for patients. Other initiatives were beingtrialled to find out what patients want. One was the use of ahand-held computer notebook device for patients to use ina survey.

Governance arrangementsAny issues raised in the outpatient departments would beescalated to the service development directorate and theboard where necessary. We asked patients about the issueof timely appointments and waiting times in the clinics,which remain an issue for some. There was significant workbeing completed to improve patient experience in thisarea.

Leadership and culturePart of the trust vision is to deliver excellence and value inpatient care. There was a clear responsibility within the

trust when issues were raised. Outpatient sisters and thetrust project manager were involved in the outpatientssteering group monthly meetings. This meant that therewas communication from and to the trust to effect changesto benefit the patient experience.

Patient experiences, staff involvement andengagementThe patient experience programme had included the“Friends and Family test” (FFT) and would be implementedacross all outpatients by the end of 2014. We saw anexample in the hospital where a poster displayed “yousaid” and “we did” as a service improvement for patientsand carers from their feedback.

Learning, improvement, innovation andsustainabilityThe trust had set out their transforming patient experiencestrategies for 2014 to 2016. We looked at recent meetingminutes to see what innovation had been started. Staff wespoke with told us that the hospital was currently goingthrough a re-profiling of outpatients. This is a review of theway that outpatients is organised and managed to ensurethat the capacity within clinics meets increasing demand toimprove targets. The trust used Royal College guidelines toinform the work, for example; on the number of patientsseen and appointment duration. This was work in progressand had not been rolled out to all outpatients departmentsyet.

Outpatients

Good –––


Action we have told the provider to takeThe table below shows the essential standards of quality and safety that were not being met. The provider must send CQCa report that says what action they are going to take to meet these essential standards.

Regulated activityTreatment of disease, disorder or injury Regulation 20 HSCA 2008 (Regulated Activities)

Regulations 2010 Records

The provider had not ensured that patients on JohnWarin and Geoffrey Harris wards were protected againstthe risks of unsafe or inappropriate care and treatmentarising from a lack of proper information about them bymeans of the maintenance of an accurate record inrespect of each patient. Records did not contain all therequired information to ensure care was delivered safelyto meet the patient’s needs. Risk assessments,monitoring records and care plans were not all fullycompleted and were not explicit in how risks were to bemanaged and care was to be provided. This placedpatients at risk of not receiving the care they needed.

Regulation 20 (1) (a)

Regulation

This section is primarily information for the provider

Compliance actions


CQC Churchill report

Documents

Transcript of CQC Churchill report