The Cherwell Hospital

On this page

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

The service provided and maintained safe systems of care, in which safety was managed, monitored and assured. There was continuity of care, including when patients moved between different services. There was a positive culture of safety based on openness and honesty. Concerns about safety were listened to, safety events were investigated and lessons were learned to continually identify and embed good practices. The service protected patients from harm and abuse. Managers ensured equipment and facilities supported the delivery of safe care. The service effectively managed infection prevention and control risks. The service provided qualified, skilled and experienced staff, who worked together effectively to provide safe care that met patients individual needs, medicines were stored, prescribed, administered and documented line with best practice and guidance.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Incident policies were regularly reviewed and up to date. Incidents were investigated in line with policy guidance.

Staff told us they knew how to access and use incident reporting systems. There was an open and honest learning culture where staff felt safe to raise issues and concerns. Managers told us they used incidents and near misses as an opportunity to learn and improve care. Managers shared learning from incidents at daily huddles and monthly team meetings. At provider level, incidents were shared across sites to ensure cross service learning.

Patient pathways provided clear guidance and support to staff and were easily accessible. Pathways included; complex patients, day case knee and hip replacement, and enhanced recovery. Since the enhanced recovery was introduced in 2020, performance data showed patient length of stay had significantly reduced. The service used clearly defined discharge criteria. Discharges were planned in conjunction with multidisciplinary teams as well as patients and families. There were robust systems for securely sharing information with patients GP’s. The hospital used the same systems as their local NHS trust to ensure safe and efficient transfer of information. Managers now had safe systems and processes to monitor World Health Organisation Five Steps to Safer Surgery Standards were being met.

Staff advised us the newly developed patient pathways for complex patients demonstrated positive outcomes for patients, for example, audits showed there was a reduced amount of time in hospital recovering. Staff told us managers had built relationships with the local NHS to provide smooth handover of care in the event of urgent transfer. Managers regularly met with third party care providers to ensure good communication and continuity of care across services.

We saw evidence when safeguarding concerns were raised, that concerns were acted on and shared quickly and appropriately. Staff told us they knew who the onsite safeguarding lead was, and where to seek support if they required help and advice. Staff advised us they felt supported by managers and had opportunities to reflect and take time out after making a safeguarding referral to the local authority. Staff were trained to the required standards for adult and children safeguarding. Managers met with third parties, for example the local NHS trust and local authority to ensure all partner agencies worked cohesively to safeguard patients, their friends and families. Managers also produced a monthly safeguarding newsletter that included up to date best practice guidance and examples of safeguarding referrals from across all provider locations. Staff were given the opportunity to discuss cases and review best practice and learning.

Safeguarding policies were up to date with the latest guidance and reviewed regularly. Staff regularly completed scenario training where they could practice how they would act in different safeguarding situations. We saw evidence that concerns were acted on and shared quickly and appropriately.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

Staff and managers told us there was sufficient numbers and types of equipment to support patients and ensure a safe service.

The service had systems in place for testing, maintaining and replacing equipment. All equipment had individual identification numbers in order to track issues and concerns. Staff completed health and safety training, including fire safety training and practice of evacuation. We saw evidence of appliance and water testing to ensure safety. Managers used a barcoding system to monitor stock levels of consumables and rotated stock to ensure expiry dates were not exceeded.

Staff completed mandatory training appropriate to support them in their role. Training was a mix of face to face and eLearning. Training completion rates met the providers benchmarking standards. Managers ensured staff were allocated time to complete training and 100% of staff had received an appraisal within the 12 months prior to assessment. Staffing levels were managed according to patient acuity and staff competencies/skill mix and rotas demonstrated actual staffing levels reflected planned requirements.

Staff told us they were provided opportunities for professional growth and development. The hospitals provider company made arrangements to pay for staff university and training courses and we were given numerous examples of this enabling staff upskilling. Staffing was based on patient numbers and acuity. Staff advised us they felt the service was sufficiently staffed, both in terms of numbers and qualifications to ensure the safety of patients.

Staff told us there was sufficient personal protective equipment, for example, gloves and aprons in a variety of sizes in accordance with Health and Safety Executive standards.

The hospital used an inhouse cleaning service but contracted out deep cleaning requirements to a third party. Staff received competency training for cleaning theatres. Staff regularly completed cleaning audits, including hand hygiene audits and demonstrated action plans where standards were not met. The hospital now had a system for labelling equipment when it had been cleaned between usage. At our previous inspection we noted a scrub sink was located adjacent to the theatre, whilst compliant at the time the hospital was built, it no longer met infection control standards. Managers had signed off refurbishment plans due to start in spring 2024. Managers regularly completed risk assessments and taped off an area around the sink to create a ‘clean zone’ to monitor the area until the refurbishment was completed.

In the 12 months prior to assessment the service had zero cases of hospital acquired infections, for example; Clostridium Difficile, a bacterium that causes an infection of the colon; MRSA, a type of bacteria that usually lives harmlessly on the skin. But if it gets inside the body, it can cause a serious infection that needs immediate treatment with antibiotics; MSSA, a bacterial infection that develops when bacteria enter the body through a cut or wound on the skin or E-Coli, bacteria that can cause infections in your gut.

Staff and managers told us they monitored medicine storage temperatures. Staff told us that guidance was now in place for them to follow in the event temperatures exceeded the acceptable range.

Since the last inspection the service had introduced a pharmacist position. The pharmacist was responsible for ordering, storing, and auditing all medicines. The service had clear guidelines and processes for using controlled drugs that met Home Office standards. The pharmacist maintained oversight of medicines standard operating procedures and there was now a process for checking staff understanding where procedures were introduced or updated. Medicines were securely stored using a key and code lock.