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Oxford University Hospitals NHS Foundation Trust

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Care Quality Commission Inspection

The Trust is governed by a regulatory framework set by the Care Quality Commission (CQC) which has a statutory duty to assess the performance of healthcare organisations. The CQC requires that hospital trusts are registered with the CQC and therefore licensed to provide health services.

The Trust continues to be registered without conditions by the Care Quality Commission to provide health services.

The CQC provides assurance to the public and commissioners about the quality of care through a system of monitoring a trust's performance across a broad range of areas to ensure it meets essential standards. The CQC assessors and inspectors frequently review all available information and intelligence they hold about a hospital, and depending on what this tells them, they may choose to inspect a hospital to ensure standards are being maintained.

You can find out more about the CQC here:

Care Quality Commission rates the Trust as 'good'

The CQC's Chief Inspector of Hospitals inspected all four of our hospital sites in Oxford and Banbury as part of the CQC's new inspection regime. The CQC report rates the Trust as 'good' with a small number of areas for improvement. The CQC inspection team looked at the quality and safety of the care provided by the Trust based on the things that matter most to local people.

Individual hospital ratings

John Radcliffe Hospital Requires improvement
Horton General Hospital Good
Churchill Hospital Good
Nuffield Orthopaedic Centre Good

Our inspection

In February 2014 a team of 51 inspectors visited the Trust's four hospital sites for two days and made unannounced spot checks on 2 and 3 March. The CQC spoke to patients, visitors, carers and staff to form an overall impression of the services the Trust provides and to rate the organisation and its services in five areas (known as domains):

  • safe, effective, caring, responsive to people's needs, well led

The CQC also held two public meetings, one in Oxford and one in Banbury, to hear from local people about patients' experiences, which were overwhelmingly positive. During the two weeks of the visit the inspectors repeatedly tested out their initial findings and have now given the Trust an overall rating of 'good' in all five of the above domains.

Among the many positive findings, the report provides a clear endorsement of our staff, who were observed providing compassionate and excellent care throughout our four hospitals.

Of 115 areas inspected across the Trust, 11 were were identified as 'requiring improvement'. At the John Radcliffe Hospital, most of the services were delivered to a good standard, although the inspectors found that both Emergency Department and surgery required some improvements. The report highlighted problems with staff shortages within the maternity department and on surgical wards and theatres; high bed occupancy; and failure to meet the national Emergency Department target to admit, transfer or discharge patients within four hours.

The CQC identified the following areas as actions the Trust must take:

  • The Trust must plan and deliver care safely and effectively to people requiring emergency, surgical and outpatient care.
  • There must be enough qualified, skilled and experienced staff to safely meet people's needs at all times.
  • The Trust must plan and deliver emergency care to people in a way that safeguards people's privacy and dignity.
  • Staff must receive suitable induction in each area that they work.
  • The Trust must ensure that newly qualified midwives are appropriately supported.
  • Patient records must accurately reflect the care and treament for each patient in line with good practice.

The following were highlighted as areas of good practice:

  • The system the Trust used to identify and manage staffing levels was effective and responsive to meet the needs of the hospitals.
  • Services were innovative and professional.
  • Caring compassionate staff throughout the four hospitals.
  • Managers had a strong understanding of the risks in service and improvements required. Incident reporting and monitoring was well managed and the learning from incidents was evident. There was a strong commitment, supported by action plans, to improve the service.
  • Staff worked well between teams. The value of an effective multidisciplinary approach, in improving outcomes for patients, was understood and actively encouraged.
  • It was evident that significant efforts had been made to improve the effective discharge of patients within medical areas. The hospital was working closely with commissioners, social services and providers to improve the transfer of patients to community services.
  • There was good learning from incidents within critical care which translated into training and safer practice.
  • There were processes in place throughout the hospitals which took into account patients' diversity. These included interpretation service and information provided in different formats according to patients' needs.
  • The Trust internal peer review process, in which over 100 clinical areas had been reviewed in a three month period across the Trust.

The Board praises staff

The Trust's Chief Executive, Sir Jonathan Michael, and Chairman Dame Fiona Caldicott, thank staff for their efforts, as CQC inspectors noted in their recent inspection report 'caring and compassionate staff throughout the four hospitals who worked well between teams and valued the benefits of working across different disciplines'.

CQC patient leaflets

Read more about National Standards at the link below.

More details of the CQC's new intelligent surveillance model can be found on the CQC website.