Gloucestershire Royal Hospital

Updated 23 May 2024

Gloucestershire Hospitals NHS Foundation Trust received authorisation on 1 July 2004. It was formed from Gloucestershire Hospitals NHS Trust, which was established following a reconfiguration of health services in Gloucestershire in 2002. The Trust provides acute hospital services from two large district general hospitals, Cheltenham General Hospital (CGH) and Gloucestershire Royal Hospital (GRH). Maternity Services are also provided at Stroud Maternity Hospital. Outpatient clinics and some surgical services are provided by Trust staff from community hospitals throughout Gloucestershire. The Trust also provided services at the satellite oncology centre in Hereford County Hospital. 

We carried out this short announced focused inspection because at our last inspection in April 2022, we rated the trust overall as requires improvement and two warning notices were issued for Surgery and Maternity. We only visited the maternity unit at Gloucestershire Royal Hospital at this inspection.

At our last inspection, carried out on the 6 and 7 April for maternity and the 12 and 13 April for Surgery, 2022 (on site) and the subsequent provision of evidence, the Commission found that:

Surgery

1. Areas within Gloucester Royal Hospital were being used outside of their intended purpose with a lack of mitigation, timely risk escalation and insufficient governance processes.

2. There was a lack of assessment of risks to the health and safety of service users receiving the care and treatment.

3. There was not an effective governance systems or processes and that Standard Operating Procedures for theatre care and treatment were out of date or overdue a review

See the surgery section for what we found during this inspection.

Maternity

1. There was a lack of assessment of risks to the health and safety of service users receiving care and treatment.

2. There was not enough staff to support the provision of safe care. There was a lack of assessment of staff competence and skills to ensure the delivery of safe care. There were insufficient numbers of suitably qualified staff to deliver and manage the maternity triage service or the induction of labour process.

3. The governance systems and processes did not work effectively to ensure the oversight of the service and to learn from incidents and improve practice to keep service users safe.

Following the inspection, the trust was served a warning notice under Section 29A of the Health and Social Care Act 2008, requiring them to make significant improvements. This was to ensure safeguarding training level 3 was provided for all staff and incidents to be investigated in a timely way so learning can be shared quickly to reduce the risk of it happening again. This is a repeat of part of the warning notice issued following the inspection in April 2022.

See the maternity section for what we found during this inspection.

We did not rate this surgery at this inspection. The previous trust rating of ​requires improvement​ remains.

Updated 7 February 2019

Our rating of this service improved. We rated it as good because:

• We rated safe, effective, caring and well-led as good and responsive as requires improvement. Overall, we rated the service as good.
• Staff understood how to protect patients from abuse, completed relevant risk assessments and kept clear and legible records of patient care.
• The effectiveness of the service had improved since the last inspection. The service used audit processes to monitor patient outcomes and used this information to improve services. Patients pain was well managed, staff worked together for the benefit of patients and the trust ensured staff were competent for their roles.
• The care provided by staff continued to be good. People were supported, treated with dignity and respect, and were involved as partners in their care.
• The service met the needs of people it supported. Staff treated patients as individuals and supported patients living with dementia or a learning disability well.
• The management of the service had improved since the last inspection. We found the leadership, governance and culture supported the delivery of high-quality care. There were clear governance processes from ward level up to the trust board. Staff were well engaged with quality improvement projects.

However:

• Systems and processes to keep people safe were not always followed in relation to infection control and medicines management. Compliance with mandatory training for medical staff needed to improve and the environment of some areas did not always ensure people were safe.
• Performance in national audits was variable and outcomes for stroke patients needed improvement.
• The responsiveness of the service required improvement as national targets for referral to treatment times were not met for most medical specialities and the trust was not producing reliable data on referral to treatment times.
• In well-led, risk management processes needed to be improved as risks were not always graded, mitigated and reviewed appropriately.

Updated 19 June 2015

Overall, services for children and young people were found to be good. Children received excellent care from dedicated, caring and well trained staff who were skilled in working and communicating with children, young people and their families. Children, young people and their families were involved in the children’s and young people’s care, and the comments we received were all very positive.

The arrangements for safeguarding were good and improving, although we had some concerns about the numbers of referrals being received and the lack of staff to deal with those referrals in a timely way. We also had concerns about the medical cover for middle grade doctors on both the neonatal and children’s units.

Updated 19 June 2015

The effectiveness, caring and leadership of the service were outstanding, and safety and responsiveness were good. Treatment, care and rehabilitation by all staff were delivered in accordance with best practice and recognised national guidelines. There was a holistic and multidisciplinary approach to assessing and planning care and treatment for patients. Patients were at the centre of the service and the overarching priority for staff. Innovation, high performance and the highest quality care were encouraged and acknowledged. All staff were engaged in monitoring and improving outcomes for patients. They achieved consistently good results for patients who were critically ill and with complex problems and multiple needs.

Patients were truly respected and valued as individuals. Feedback from people who had used the service, including patients and their families, had been exceptionally positive. Staff went above and beyond their usual duties to ensure that patients experienced compassionate care and that care promoted dignity. People’s cultural, religious, social and personal needs were respected. Innovative caring for patients, such as the development of patient diaries, was encouraged and valued.

The leadership, governance and culture were used to drive and improve the delivery of high quality person-centred care. All the senior staff were committed to their patients, their staff and their unit, with an inspiring shared purpose. There was strong evidence and data to base decisions upon and drive the service forwards from a clear, approved and accountable programme of audits. There was a high level of staff satisfaction, with staff saying they were proud of the unit as a place in which to work. They spoke highly of the culture and consistently high levels of constructive engagement. Innovation and improvement was celebrated and encouraged, with a proactive approach to achieving best practice and sustainable models of care.

There was a strong track record on safety, and lessons were learned and improvements made when things went wrong. This was supported by staff working in an open and honest culture and by a desire to get things right. Staff responded appropriately to changes in risks to patients. There was high quality equipment and a safe environment. The unit was clean and well organised. Staff adhered to infection prevention and control policies and protocols. There were good levels of nursing and medical staff meeting the Core Standards for Intensive Care Units to keep patients safe. There was a daily presence of experienced consultant intensivists and doctors, and rarely any agency nursing staff or locum cover used. Patients’ records were excellent, clear, legible and contemporaneous, although their security needed to be improved.

Some improvement was needed to ensure stocks of medicines and other consumables were stored safely, were in date, and details were recorded accurately. The patient harm data was low, but the internal and external recording and display of some information could be improved.

The critical care service responded well to patients’ needs. There were bed pressures in the rest of Gloucestershire Royal Hospital that sometimes meant patients were delayed on discharge from the unit, but the number of incidences was only just above the NHS national average for similar units. Some patients were discharged onto wards at night, when this was recognised as less than optimal for patient wellbeing, but the rate was the same as the NHS national average. There was a very low rate of elective surgical operations being cancelled because a critical care bed was not available.

The facilities in critical care were excellent for patients, visitors and staff, and met all the modern critical care building standards. The trust had responded to the need to improve patient flow by opening a new surgical high dependency unit with four new beds (and expansion capability to six beds) in January 2015.

Patients were treated as individuals and there were strong link nurse roles for all aspects of patient need, including learning disabilities, dementia and mental health. There were no barriers to people who wanted to complain. There were, however, few complaints made to the department. Those that had been made were fully investigated and responded to with compassion and in a timely way. Improvements and learning were evident from any complaints or incidents.

Updated 5 July 2017

We rated this service as Good because:

• End of life care provided at Gloucestershire Royal Hospital was safe, effective caring, responsive and well led because:
• The processes in place to keep people safe for end of life care were good. Staff in the end of life care team and other areas understood their responsibilities to raise concerns, record safety incidents and report them. Lessons were learned and improvements were made when things went wrong.
• Patient’s records demonstrated that nutrition and hydration needs were assessed and appropriate actions were documented as followed in patients’ individual care plans.
• Records documented discussions with relatives around what to expect with the dying process.
• Risks to patient’s receiving care at end of life were assessed by ward staff with appropriate assessments recorded in medical records for example the prevention and management of pressure ulcers and falls.
• Staff we spoke with on the wards understood that end of life care could cover an extended period for example in the last year of life and also applied to patients with non-cancer diagnoses such as dementia. Staff, teams and services worked together to deliver effective care and treatment.
• Staff we observed on wards and in the community delivering end of life care to patients were compliant with key trust policies such as infection control.
• Arrangements in place for managing medicines kept patients safe. Medicines to relieve pain and other symptoms were available at all times. Wards had adequate supplies of syringe drivers (devices for delivering medicines continuously under the skin) and the medicines to be used with them.
• There were reliable systems, processes and practices in place to keep patients safe and safeguarded from abuse.
• The staffing levels and skill mix of the nurse and medical personnel in the specialist palliative care team were planned and reviewed and supported safe practice. We saw evidence of a yearly education programme of end of life care for medical, nursing and allied health professionals. This included: resuscitation, syringe driver training, quarterly end of life study days and symptom management.
• The specialist palliative care team responded promptly to referrals, usually within one working day.
• Patients were treated with kindness, dignity, respect and compassion. Staff took the time to interact with people who received end of life care and those close to them in a respectful and considerate manner.
• We saw many written compliments about how caring staff were in the inpatient and community specialist palliative care team. We saw that patients’ and those people close to them, were involved as partners in their care.
• The specialist palliative care team and wards staff understood the impact a patients’ care, treatment or condition had on their wellbeing and on those people close to them.
• Emotional support for patients and relatives was available through the in-patient and community specialist palliative care team, the chaplaincy team and bereavement services. Staff had access to support through their own teams when needed.
• Services were delivered and additional services planned in order to effectively meet patient’s needs. Plans and actions included audit to inform future planning so that the end of life team could inform better decision making with patients they cared for
• The bereavement office was one of two sites in the country involved in a pilot project to improve death certification which was more supportive to bereaved relatives and provided better oversight of causes of death.
• There was a clear vision and strategy to deliver care at end of life. The governance framework for end of life care ensured that responsibilities were clear and that quality, performance and risks were understood and managed.
• Leadership encouraged openness and transparency and promoted good quality care. There were leads on the wards who supported the development and delivery of high quality end of life care.
• Services within specialist palliative and end of life care had been continuously improved and sustainability supported since the last inspection March 2015.

However:

• Documenting ‘Do Not Attempt Cardio-Pulmonary Resuscitation’ (DNACPR) decisions had improved since the last inspection however concerns regarding DNACPR remained. For example not all DNACPR having relevant clinical information and not all patients or those close to them being recorded as involved in discussions about resuscitation. These concerns were not identified as a risk and did not feature on a risk register
• There were no centrally held training records for syringe driver training or competency for ward staff.
• There was not a full understanding of performance for all aspects of end of life care. For example the percentage of patients dying in their preferred location and the percentage of patients discharged within 24 hours were not known for all wards or hospital sites.
• There was no risk register specific to end of life care for the trust so oversight of all end of life risk was not easy.
• When we reviewed maintenance records some provided were out of date. The trust told us they were clear that equipment listed was not in use. We saw email communication from directors supporting this.
• There was not a seven day face to face service provided by the in-patient and community end of life care team. The trust provided a face to face service 9-5 Monday to Friday. Out-of-hours there was a telephone advice line available 24 hours, 7 days a week for health care professionals to access.
• Some of the ‘white rose’ symbols used to locate the mortuary at the hospital were not easy to follow. Signs were not always at eye level for someone walking or in a wheelchair and there were long gaps in signage that led to confusion. Mortuary and bereavement officers told us relatives had commented they were useful. Some relatives had reported they appreciated these signs. However bereavement office staff accompanied relatives when they knew people were attending the mortuary.

Updated 10 November 2023

Updated 7 February 2019

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new findings directly with previous ratings.

We rated it as good because:

• Staff understood how to protect patients from abuse and there were clear processes for reporting safeguarding concerns.
• The service controlled infection risk well. Staff kept themselves, equipment and the premises clean and used control measures to prevent the spread of infection.
• There were systems in place to manage maintenance of equipment and repair faults when identified.
• Staff could identify and respond to a deteriorating patient within the outpatient environment, including medical emergencies.
• Staff kept appropriate records of patients care and treatment. Records were clear, up-to-date and available to all staff providing care.
• The service prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time.
• Staff understood their responsibilities to report near misses, patient safety concerns and incidents.
• Nutrition and hydration was considered as part of the patient assessment. Refreshments were also available to patients in the outpatient setting.
• The service made sure staff were competent for their roles. Professions worked together to provide seamless patient care, including when care was provided across different specialisms.
• Patients were treated with compassion, kindness, dignity and respect throughout their visits to outpatient services.
• Staff provided emotional support to patients to minimise their distress. We observed staff providing emotional support to patients and relatives during their visit to the department.
• The services provided reflected the needs of the local population by offering choice, flexibility and continuity of care.
• The service took account of patients’ individual needs and considered different needs and preferences. Reasonable adjustments were made and staff supported people with additional needs.
• Staff within outpatients worked hard to ensure people with learning disabilities were able to access services.
• The trust identified where a system-wide approach was needed to meet the needs of the local population. Within endocrinology, rheumatology and dermatology, work was ongoing with commissioners and partners in primary care to find solutions to the demand for services.
• Staff supported patients with additional needs such as patients living with dementia. An alert was placed on patients’ records and early appointment times allocated to reduce anxiety.
• Translation services were available for patients whose first language was not English.
• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.
• The trust had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. There was a positive culture within outpatient services.
• The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff and patients. The trust had produced a “Transformation Plan” for the outpatient’s services they provided.
• Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff were proud of their work in the outpatient services.
• There were appropriate levels and structures of governance across outpatient services to ensure safety was monitored and improvements supported. There were clear lines of accountability and reporting.

• The trust engaged well with patients, staff, and the public to plan and manage appropriate services, and collaborated with partner organisations effectively.
• There was a focus on learning, improvement and innovation throughout outpatient services. Staff were engaged with the outpatient transformation and very positive about delivering an improving and innovative service.

However:

• Outpatient services were primarily a five-day service.
• Lack of space was identified as an issue in certain clinic areas.
• The introduction of a new patient appointment booking system, had presented a number of difficulties in the delivery of services. There had been large increases in waiting times and a build-up of delayed clinic letters that needed to be sent out.
• The trust has been unable to report referral to treatment data to NHS England since November 2016 because of data quality issues following the introduction of a new electronic patient record system in December 2016.
• Patients could not always access services when they needed them. There was not always timely access to treatment. The trust could not be assured that waiting times for treatment were and arrangements to admit, treat and discharge patients were in line with good practice.

Updated 7 October 2022

Updated 17 June 2021