Nuffield Health The Manor Hospital Oxford is operated by Nuffield Health Group. The hospital facilities include 25 consulting rooms, six surgical theatres, 71 private en-suite bedrooms, two minor procedure suites for day case and outpatient surgery, and a radiology unit including: mammography, ultrasound, MRI & CT scans. There was also a seven bedded critical care unit and a physiotherapy department;

Nuffield Health The Manor Hospital Oxford is operated by Nuffield Health Group. The hospital facilities include 25 consulting rooms, six surgical theatres, 71 private en suite bedrooms, two minor procedure suites for day case and outpatient surgery, and a radiology unit including: mammography, ultrasound, MRI & CT scans. There was also a seven bedded critical care unit and a physiotherapy departmen; and two intervention suites for radiology and cardiology. The children and young people’s inpatient service had six single en suite rooms in one dedicated area.

The hospital provides surgery, medical care, critical care, services for children and young people, and outpatients and diagnostic imaging.

The hospital is currently registered for the regulated activities surgical procedures, diagnostic and screening procedures, and treatment of disease, disorder or injury.

We inspected critical care services and services for children and young people. We inspected the services using our focused inspection methodology to assess if improvements had been made in children services, and to inspect the critical care service as the hospital was not providing the service at our last inspection. We carried out the unannounced inspection on 30 August 2018

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

During the inspection, we visited the children’s ward, theatres and recovery, and the outpatient department. We spoke with eight members of staff including registered children nurses, registered general nurses, reception staff, medical staff, operating department practitioners and senior managers. We spoke with three patients and three parents. We reviewed 10 sets of patient records. Following our inspection, we had telephone conversations with parents of three children who had attended the hospital in the previous 12 months.

We also visited the critical care unit. We spoke with six members of staff including registered nurses, medical staff, and senior managers. At the time of the inspection there were no patients in the hospital who had used the critical care unit. Following our inspection, we had telephone conversations with five patients or their partners who had been in the unit within the last six months.

The children and young people’s inpatient service had six single en-suite rooms in one dedicated area.

The hospital provides surgery, medical care, critical care, services for children and young people,  outpatients and diagnostic imaging.

The hospital is currently registered for the regulated activities surgical procedures, diagnostic and screening procedures, and treatment of disease, disorder or injury.

We inspected critical care services and services for children and young people. We inspected the services using our focused inspection methodology to assess if improvements had been made in children services, and to inspect the critical care service as the hospital was not providing the service at our last inspection. We carried out the unannounced inspection on 30 August 2018

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

During the inspection, we visited the children’s ward, theatres and recovery, and the outpatient department. We spoke with eight members of staff including registered children nurses, registered general nurses, reception staff, medical staff, operating department practitioners and senior managers. We spoke with three patients and three parents. We reviewed 10 sets of patient records. Following our inspection, we had telephone conversations with parents of three children who had attended the hospital in the previous 12 months.

We also visited the critical care unit. We spoke with six members of staff including registered nurses, medical staff, and senior managers. At the time of the inspection there were no patients in the hospital who had used the critical care unit. Following our inspection, we had telephone conversations with five patients or their partners who had been in the unit within the last six months.

Services we rate

Our rating of children’s service improved from requires improvement to good.

• Staff understood how to protect patients from abuse. Staff had training on how to recognise and report abuse and they knew how to apply it.

• The service had enough staff with relevant skills, training and experience to deliver safe care to children and young people.

• The service considered and took actions to lesson risks to children and young people.

• The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.

• The service followed best practice when prescribing, giving recording and storing medicines.

• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service.

• The service provided care and treatment based on national guidance and monitored the effectiveness of care and treatment via audits. Findings were used to improve the services.

• The service assessed and monitored patients pain appropriately.

• Consent to care and treatment was obtained in line with national guidance.

• Staff cared for children, young people and their families with compassion. Feedback from patients and their parents was positive about the way staff treated them. The emotional needs of children, young people and their parents were fully considered.

• Staff involved children, young people and their patients in decisions about care and treatment.

• The service was planned around meeting the needs of the local population, with appointments and admissions offered to meet the individual circumstances of each patient.

• There was clear leadership of the children and young people’s service. A lead nurse had responsibility and accountability for all the children and young people’s services in the hospital. There was identified medical leadership.

• Governance processes supported improvement to the service.

• There was an inclusive culture, with staff of all professions across the hospital working together to deliver quality care to children and young people.

• There were processes for children, young people and their parents to feedback about their experiences of care and treatment at the hospital. Staff acted on this feedback to help plan and develop its service.

• The service was committed to improving services by learning from when things went well and when they went wrong.

However,

• The service did not use systems for identifying risks and planning to eliminate or reduce risks effectively.

We rated the critical services as good.

• Systems and processes were in place and followed by staff to keep critical care unit (CCU) patients safe.

• There were sufficient numbers of staff with relevant skills and experience and up to date mandatory training in safety systems, processes and practices to deliver safe care to patients on the CCU.

• There was a good track record on safety and staff understood their responsibilities to raise concerns and incidents.

• Care and treatment was delivered in line with current evidence based guidance and standards.

• The service monitored the effectiveness of care and treatment via audits and used the findings to improve the services.

• Staff cared for patients in CCU and their families with care and compassion. Staff in the CCU involved their patients in decisions about care and treatment.

• The CCU service was planned around meeting the needs of the local population, with appointments and admissions offered to meet the individual circumstances of each patient.

• There was clear leadership of the CCU; and a lead nurse had responsibility and accountability for the CCU. There was identified medical leadership in the CCU.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with one requirement notice that affected children’s services. Details are at the end of the report.

Dr Nigel Acheson

Deputy Chief Inspector of Hospitals (London and the South)

During our inspection we spoke with ten patients and looked at the medical and nursing records for ten patients. We spoke with 23 members of staff which included the Matron, an anaesthetist, two surgeons, a radiologist and administration, portering and nursing staff.

Patients we spoke with were highly complimentary about the care and treatment they had received. One patient told us, "I was very nervous but the staff have been very reassuring, helpful and lovely. It has been personal and individualised”. We found that patients were given appropriate information and support in relation to their care and treatment and that People's privacy and dignity were respected. We observed staff interactions with people were friendly and respectful. Assessments and procedures took place in private rooms, privacy gowns were provided and the ward had a system in place to alert others when privacy was required in patients' rooms.

During our visit we saw a patient's care while they were in the operating theatre. We found that the centre had robust systems in place to ensure patients were safe during their operation.

We observed that nursing staff were responsive to patient’s needs. For example, we observed that patients were asked about their levels of pain and offered pain relief. One patient told us “I am never in pain”.

We found that patients were protected against the risks associated with medicines because the provider had safe and effective arrangements in place for the management of medicines.

Staff told us they felt well supported in their role. Comments made by the staff included “It’s a nice place to work, the team are lovely” and “we are well supported”. Patients told us that staff were knowledgeable and knew what to do for them. We looked at the training and professional development provided to staff. We found that the provider took appropriate steps to ensure that patient’s health and welfare needs would be met with competent staff.

During our inspection we looked at the provider’s quality assurance and risk management systems. We found that the provider had an effective system in place to regularly assess and monitor the quality of the service that patients received.

Before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. Two people told us that they felt fully informed by the doctors about the operations that they were going to have done. One person said " The doctors explain everything and the nurses tell you what they are going to do."

We spoke to two patients about their experience of the care provided. Patients described their care as “Excellent”, “Attentive” and “10 out of 10.” Patients were able to describe a full assessment of their care needs and were asked if there were any individual preferences they had. This meant that care was individualised and met the needs of the person.

There were effective systems in place to reduce the risk and spread of infection through having leads in individual areas who reported into the local and national infection prevention Committees. Advice could be sought from the groups infection prevention and control lead. There were systems in place to monitor the quality and effectiveness of the service which led to enhancements in the service provided.

Staff were recruited and supported appropriately. Staff said that they felt supported through training and were able to make a positive contribution to the running of the hospital.

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

Nuffield Health The Manor Hospital Oxford was purpose built and opened in 2004. The hospital is managed by the Nuffield Health Group, a not-for-profit organisation. On-site facilities include six high-specification surgical theatres, 64 private en-suite bedrooms, two minor procedure suites for day case and outpatient surgery, and a radiology unit including: mammography, ultrasound, MRI & CT scans.

Over 300 qualified consultants have practising privileges and lead the medical and surgical services. The consultants who work from the hospital predominantly have substantive post with the local acute NHS trust.

The hospital had been transitioning through a period of immense change since December 2015, with a new clinical and hospital leadership. The current manager became the registered manager in February 2016.

We inspected the hospital as part of our planned comprehensive inspection programme. We looked at the four core services provided by the hospital: medicine, surgery, outpatient and diagnostic imaging, and services for children and young people.

The announced inspection took place on 8 and 9 June 2016, followed by an unannounced visit on 22 June 2016.

The hospital was rated good for safe, effective, caring, responsive and well led services.

Our key findings were as follows:

Are services safe at this hospital?

By safe, we mean people are protected from abuse and avoidable harm.

• Staff were clear about their responsibilities to report incidents and there was a culture of learning from incidents that was promoted.

• Processes to protect people from harm, such as infection control, the safe handling of medicines and equipment safety checks were being followed.

• Patients were assessed and action was taken in response to risk. This included the assessment of patients to ensure only patients who the hospital could safely support received treatment.

• Patient records were accurately kept and stored securely. However, there were instances wherethere were no dates on prescriptions or signatures were not legible.

• Staff were aware of safeguarding and were clear about their responsibilities to safeguard people at risk.

• In General staffing levels and skill mix were planned, implemented and reviewed to keep people safe at all times. This was not the case for children and young people’s service as staffing was not in line withnational guidance.

• Staff compliance with mandatory training was generally good. Adherence with paediatric basic life support training was low.

• There was a good understanding of the principles of the duty of candour, and the need to be open and honest.

Are services effective at this hospital?

By effective, we mean that people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence.

• Care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation.

• Staff were qualified and had the skills needed to carry out their roles effectively. Staff were supported to maintain and further develop their professional skills and experience, including through appraisal.

• When patients received care from a range of different staff, teams or services, this was coordinated.

• Staff had access to the information needed to assess, plan and deliver care to people in a timely way.

• Consent to care and treatment was obtained in line with legislation and guidance, however staff did not demonstrate a clear understanding of the procedures to follow for patients who lacked capacity.

• The hospital had robust systems in place for granting practicing privileges to consultants and when necessary suspended or removed these.

• In general, patient’s pain was well managed, however for children and young people there were inconsistencies in the approach to managing their pain.

• Information about people’s care and treatment, and their outcomes, was collected and monitored. There was participation in relevant local and national audits, and other monitoring activities such as reviews of services, benchmarking and peer review. However there was no evidence of monitoring of outcomes for children and young people.

Are services caring at this hospital?

By caring, we mean that staff involve and treat people with compassion, kindness, dignity and respect.

• Feedback from patients and those close to them was positive. People were treated with dignity, respect and kindness. Patients told us they felt supported.

• Staff spent time talking with patients and they understood their care, treatment and condition.

• Staff supported patients to maintain their independence and connections with their family and friends.

• Results of the friends and family test were positive with the majority of patients recommending the hospital.

Are services responsive at this hospital?

By responsive, we mean that services are organised so they meet people’s needs.

• The hospital planned and delivered services in a way that met the needs of the local population. The importance of flexibility and choice was reflected in the service.

• Waiting times, delays and cancellations were minimal and managed appropriately. People were kept informed of any disruption.

• Patients had timely access to initial assessment, diagnosis and urgent treatment at a time to suit them.

• The needs of different people were generally taken into account when planning and delivering services, although no specific consideration had been given to ensure the service was able to meet the individual needs of people living with dementia. The general environment did not meet the needs of children and young people and provision of play and recreation within the hospital was limited to meet the needs of young children only.

• Written information was available for patients in a variety of languages, however there was limited age appropriate information for children and young people.

• Complaints and concerns were managed in a timely way, with learning from complaints shared and used to improve the quality of care.

Are services well led at this hospital?

By well led, we mean that the leadership, management and governance of the organisation assures the delivery of high-quality person-centred care, supports learning and innovations and promotes an open and fair culture.

• There was a clear statement of vision and values, driven by quality and safety. Staff were aware of the values of the organisation and were passionate about good patient care.

• Governance arrangements to monitor the quality and safety of services were in place.Although those specifically designed to monitor the quality for the children’s and young people’s service were not fully established.

• Structures, processes and systems of accountability, including governance were clearly set out, understood and effective.

• Performance issues were escalated to the relevant committees and management team through clear structures and processes.

• The hospital management team engaged and involved staff working to ensure the voices of all staff were heard and acted on.

• Staff were positive about the local leadership and felt supported.

However, there were also areas where the provider needs to make improvements.

Importantly, the provider must:

• Review children nurse staffing for the service to ensure national guidance is met.

• Patient care records are completed to recommended national standards, including signatures for all staff providing care for the patient.

• Baseline assessments are completed, including a child’s height and weight, prior to prescriptions being issued.

• Robust systems are developed for locally monitoring the quality of the children and young person service, including participation in clinical audits.

Importantly, the provider should:

• Ensure all staff are aware of and know the requirements in relation to The Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards legislation.

• Consider displaying results of safety thermometer audits.

• Ensure all staff complete paediatric basic life support training.

• A review is completed to assess the need for a competency based programme for theatre staff caring for children and young people.

• The environment in areas where children and young people are cared for, is suitable for all ages, not just young children.

• Written information is available for children and young people about their condition and the care pathway when admitted to hospital.

Professor Sir Mike Richards

Chief Inspector of Hospitals