All inspections: Gloucestershire Royal Hospital

We found that:

The gender of the staff undertaking the enhanced observations did not always reflect the gender of the young person.
There was no privacy in the young persons’ rooms, and we were told that de-escalation and restraint took place in the rooms. People moving along the corridor could see into the young person’s room.
Care plans and records did not reflect national guidance for restraint, observation, and emergency sedation.
Training records showed level 3 safeguarding training was below 50% and not all staff had received training on the mental health needs of children and young persons.
There were concerns over the competencies of registered nurses supplied by the agency to provide specialist mental health care to the young persons.
The trust medicines policy and procedures regarding the administration of emergency sedation and the observations of the patient post administration were not being followed.
Staff were not following the national guidance on the use of emergency sedation in a child or young person. Managers did not have a comprehensive oversight of the administration of emergency sedation.

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

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

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.

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.

Gloucestershire Hospitals NHS Foundation Trust provides surgical services to patients in the Gloucestershire area. Surgical care is provided at two hospital sites, Gloucestershire Royal Hospital and Cheltenham General Hospital. All surgical services across both sites are managed by one surgical division. Data was provided by the trust at divisional level and related to both locations. Therefore, information will be similar within both location reports. The surgical division consists of six service lines:

Trauma and Orthopaedics; trauma, orthopaedics and orthotics.
Head and Neck; oral maxillofacial, ears nose and throat, orthodontics, and audiology.
Ophthalmology; ophthalmology, orthoptics, optometry, diabetic retinal screening and medical photography.
General Surgery; urology, breast, vascular, upper gastrointestinal, colorectal, bariatric, urology and abdominal aortic aneurysm screening.
Theatres; theatres and day surgery.
Anaesthetics; anaesthetics, chronic and acute pain, pre-assessment, acute care response and critical care.

We carried out this unannounced inspection of surgery because of a high number of never events reported by the trust and information of concern we had received about the safety and quality of the service.

Our rating of this location went down. We rated it as inadequate because:

Not all staff had training in key skills. Infection control was not always managed well. The design, maintenance and use of facilities, premises and equipment did not always keep people safe. The service did not always have enough staff to care for patients and keep them safe. Staff did not always assess risks to patients, nor act on them. Staff did not always manage medicines well. Care records were not always kept updated. The service managed safety incidents but did not always learn lessons.
There was a mixed approach to monitoring the renewal of competencies with limited oversight of the competency of staff. Policies were not always reviewed. People could not always access the service when they needed it and waited too long for treatment.
Leaders were not always visible to frontline staff. The service had set objectives for what it wanted to achieve in the 2021/22 financial year. However, there were no clear strategies as to how to turn these aims into action nor how progress would be monitored. Not all staff felt respected, supported and valued. Staff did not feel they could raise concerns in a safe way.

However:

Managers monitored the effectiveness of the service and mostly achieved good outcomes for patients. Staff advised patients on how to lead healthier lives and supported them to make decisions about their care. Most key services were available seven days a week.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and provided emotional support to patients, families and carers.

Following the inspection, we issued a section 29a warning notice to the trust as we found significant improvement was required to surgical safety, leadership, risk management and governance.

We carried out this unannounced focused inspection of maternity services on Wednesday 6 April and Thursday 7 April 2022 because we received information giving us concerns about the culture, safety, and quality of the services. As this was a focused inspection, we only inspected safe, well-led and parts of the effective key questions.

See the Maternity section for what we found.

How we carried out the inspection

During the maternity inspection we spoke with 43 staff including the head of midwifery, consultant obstetric lead, divisional management team, consultants, clinical matrons, fetal monitoring midwife, specialist midwives, midwives, community midwives and maternity care assistants. We spoke with a service user and their relative.

We spent a day in the Gloucestershire Royal Hospital maternity services and a day in the community where we visited the community teams at Stroud and Cheltenham. At the time of the inspection the birth units at Stroud and Cheltenham were closed. We reviewed 10 sets of women’s records, reviewed clinical guidelines and governance documents. We completed six staff interviews after the on-site inspection.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Following the inspection, we issued a section 29a warning notice to the trust as we found significant improvement was required to midwifery safety, leadership and governance. The section 29a warning notice has given the trust three months to act on the significant improvements we identified.

Gloucestershire Hospitals NHS Foundation Trust provides acute hospital services from Gloucestershire Royal Hospital and Cheltenham General Hospital. The trust employs more than 8,000 staff.

We carried out an unannounced focused inspection of Gloucestershire Royal Hospital urgent and emergency care services (also known as accident and emergency - A&E) and medical care services (including older people’s care), between 8 and 10 December 2021. We had an additional focus on the urgent and emergency care pathway across Gloucestershire and carried out a number of inspections of services across a few weeks. This was to assess how patient risks were being managed across health and social care services during increased and extreme capacity pressures.

As this was a focused inspection at Gloucestershire Royal Hospital, we only inspected parts of five our key questions. For both core services we inspected parts of: safe, responsive, caring and well led. We included parts of effective in medical care. We did not inspect effective in emergency and urgent care at this visit but would have reported any areas of concern.

The emergency department was previously rated as good overall with safe and responsive as requires improvement. Medical care was previously rated as good overall with responsive as requires improvement.

For this inspection we considered information and data on performance for the emergency department and medical care. This inspection was partly undertaken due to the concerns this raised over how the organisation was responding to patient need and risk in the emergency department and the wider trust in times of high demand and pressure on capacity. We were concerned with waiting times for patients, delays in their onward care, treatment and delayed discharges, as well as delayed and lengthy turnaround times for ambulance crews. It was also to review actions we asked the trust to take from our last inspection.

We looked at the experience of patients using urgent and emergency care and medical care services in Gloucestershire Royal Hospital. This included the emergency department, medical wards and areas where patients in that pathway were cared for while waiting for treatment or admission. We visited services and departments that patients may encounter or use during their stay. We also went to wards where patients from the emergency department were admitted for further care. This was to determine how the flow of patients who started their care and treatment in the emergency department and those cared for on medical wards, was managed by the wider hospital.

A summary of CQC findings on urgent and emergency care services in Gloucestershire

Urgent and emergency care services across England have been and continue to be under sustained pressure. In response, CQC is undertaking a series of coordinated inspections, monitoring calls and analysis of data to identify how services in a local area work together to ensure patients receive safe, effective and timely care. On this occasion we did not inspect any GPs as part of this approach. However, we recognise the pressures faced by general practice during the COVID-19 pandemic and the impact on urgent and emergency care. We have summarised our findings for Gloucestershire below:

Provision of urgent and emergency care in Gloucestershire was supported by health and social care services, stakeholders, commissioners and the local authority. Leaders we spoke with across a range of services told us of their commitment and determination to improve access and care for patients and to reduce pressure on staff. However, Gloucestershire had a significant number of patients unable to leave hospital which meant the hospitals were full and new patients had long delays waiting to be admitted.

The 111 service was generally performing well but performance had been impacted by high call volumes causing longer delays in giving clinical advice than were seen before the pandemic. Health and social care leaders had recently invested in a 24 hour a day, seven day a week Clinical Assessment Service (CAS). This was supported by GPs, advanced nurse practitioners, pharmacists and paramedics to ensure patients were appropriately signposted to the services across Gloucestershire.

At times, patients experienced long delays in a response from 999 services as well as delays in handover from the ambulance crew at hospital due to a lack of beds available and further, prolonged waits in emergency departments. Patients were also remaining in hospital for longer than they required acute medical care due to delays in their discharge home or to community care. These delays exposed people to the risk of harm especially at times of high demand. The reasons for these delays were complex and involved many different sectors and providers of health and social care.

Health and social care services had responded to the challenges across urgent and emergency care by implementing a range of same day emergency care services. While some were alleviating the pressure on the emergency department, the system had become complicated. Staff and patients were not always able to articulate and understand urgent and emergency care pathways.

The local directory of services used by staff in urgent and emergency care to direct patients to appropriate treatment and support was found to have inaccuracies and out of date information. This resulted in some patients being inappropriately referred to services or additional triage processes being implemented which delayed access to services. For example, the local directory of services had not been updated to ensure children were signposted to an emergency department with a paediatric service and an additional triage process had been implemented for patients accessing the minor illness and injury units to avoid inappropriate referrals. Staff from services across Gloucestershire were working to review how the directory of services was updated and continuing to strengthen how this would be used in the future.

We found urgent and emergency care pathways could be simplified to ensure the public and staff could better understand the services available and ensure people access the appropriate care. Health and social care leaders also welcomed this as an opportunity for improvement. We also identified opportunities to improve patient flow through community services in Gloucestershire. These were well run and could be developed further to increase the community provision of urgent care and prevent inappropriate attendance in the emergency departments.

There was also capacity reported in care homes across Gloucestershire which could also be used to support patients to leave hospital in a timely way. The local authority should be closely involved with all decision-making due to its extensive experience in admission avoidance and community-based pathways.

Summary of Gloucestershire Hospitals NHS Foundation Trust - Gloucester Royal Hospital

We found:

Staff understood how to protect patients from abuse and acted on any concerns.
The services mostly controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean and most staff wore personal protective equipment in line with trust policy. However, some hand gel containers were found to be empty.
Patients had an assessment of their infection risk and other clinical risks on arrival at the emergency department and were treated according to their priority of need. Those who needed urgent care received it.
Managers had reviewed staffing needs and recently increased the total number of nurses and medical staff recruited. Bank and agency staff were used to fill gaps in the rotas but some shifts could not be filled. Managers were continuing recruitment processes for new roles. Locums were used to fill gaps in medical rotas and managers ensured senior staff were available on each shift.
The services had enough medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care. Key services were available seven days a week to support timely patient care.
Staff were empathetic and caring when treating patients and demonstrated an understanding of how patients may be feeling when receiving treatment in the emergency department. Patients felt informed of their treatment choices and praised staff for care they received. A newly appointed patient experience lead for the emergency department had a positive impact on patient experience.
The services were inclusive and took account of patient’s individual needs and preferences. Staff made reasonable adjustments to help access services. They coordinated care with other services and providers.
Managers risk assessed, adapted and rearranged services at times of extreme capacity pressures to help staff provide safe care and treatment for patients. Staff worked hard to provide care and treatment for patients who stayed in the emergency department longer than anticipated due to capacity pressures on the hospital.
Leaders and teams used systems to manage risk and performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact. Staff contributed to decision-making to help avoid compromising the quality of care.
Managers demonstrated the skills and abilities to run the services. They understood and managed the priorities and issues the services faced. Level of pressure was communicated to executive leaders and across the trust. They were supportive and caring for patients and staff.

However:

Due to capacity pressures and the emergency department often being at full capacity areas were reconfigured in the emergency department. Some areas were small and did not allow for patients to socially distance while waiting for treatment. Assessment and prioritising patients’ needs were key for staff but space was limited. However, patients’ risks were assessed to maintain their safety and follow social distancing rules. Patient referrals to other specialties were not always responded to promptly. This led to some areas being used for more patients than they were designed for. Staff did their best to protect patients’ privacy and dignity but lack of space led to this being less than ideal at times.
There were still some gaps in nursing rotas in both the emergency department and medical care which could not be filled using bank or agency staff. In the emergency department these had reduced since our last inspection. There were not enough children’s trained nursing staff to cover every shift in the emergency department. Paediatric colleagues provided support and additional training in paediatric skills was provided for staff while managers undertook recruitment drives to attract paediatric trained staff.
Capacity pressures in the emergency department meant not all patients received treatment promptly, but they were assessed quickly for risk on arrival and prioritised for treatment. A major part of the problem with access to beds for patients in the emergency department was from the high number of patients who were medically fit to leave on hospital wards. They were waiting for further social care support to enable their safe discharge.
Due to pressures on bed capacity in medical care, there were times when patients were cared for in areas not designed for that purpose, and there were occasional mixed-sex breaches in medical care.
In medical care, patients were being moved sometimes multiple times, sometimes at night, in order to admit them to the right place once a bed became available. Some patients were needing longer stays while they awaited treatment.
Some staff in medical care had the perception that some leaders were not always visible and approachable for staff. Staff morale was low due to the immense and unrelenting pressures which had been ongoing for a number of years.

How we carried out the inspection

At Gloucestershire Royal Hospital, we spoke with 18 patients and their families, and 37 staff, who included nursing, medical, administration staff and service leads. We observed care provided; a safety huddle attended by eight staff; reviewed relevant policies; documents; and 18 patient records.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

We carried out a focused inspection of Gloucestershire Royal Hospital urgent and emergency care service (also known as accident and emergency – A&E) on 30 March 2021 as part of our winter pressures programme. As this was a focused inspection, we only inspected parts of three of our key questions: safe, responsive and well led. We did not inspect effective or caring on this visit, but we would have reported on them if we found areas of concern. At our previous inspection in 2018, caring and effective were rated as good.

For this inspection, we considered information, data and the concerns this raised over the ability of the department to respond to patient need (also known as performance) of the department and the wider trust in relation to responsive care (around timely patient flow) and waiting times for patients. We were also concerned with delayed and lengthy turnaround times for ambulance crews.

Our inspection had a short announcement (around 30 minutes) to enable staff to arrange to meet with us and for us to carry out our work safely and effectively.

Focused inspections can result in an updated rating for any key questions that are inspected if we have inspected the key question in full across the service and/or we have identified a breach of regulation and issued a requirement notice, or taken action under our enforcement powers. In these cases, the ratings will be limited to requires improvement or inadequate.

Previous ratings were not all updated during this inspection. However, the rating for urgent and emergency care for safe and overall went down. We rated safe and the urgent and emergency care overall as requires improvement. The previous rating for responsive remained as requires improvement and well led remained as good. We did not change the overall ratings for the location.

Please refer to the ‘areas of improvement’ section for more details.

During our inspection we found:

The reconfiguration and use of some areas of the department did not always keep patients and staff safe despite the efforts the service had made during the pandemic. We were concerned with crowding in the department, which did not promote safe social distancing.
Patients’ dignity and respect were compromised, and social distancing was not always possible because patients were cared for in corridors of the department.
The service did not have enough medical staff and nursing staff to meet the recommended guidance for the type and size of the department or to be able to expand the service. The department did not have middle grade and junior doctors throughout various parts of the day but managed to cover the department through the use of locum doctors, bank and agency staff as required.
Patients did not always receive care and treatment promptly, although there were significant efforts made to keep them safe. Pressure from high demand, COVID-19 restrictions, a lack of beds in the rest of the hospital available for patient transfer, and patients being more unwell meant patients attending the urgent and emergency care service did not get seen in a time considered safe and responsive to their needs.
Patient handover from ambulance crews and waiting-time performance for onward admission to the hospital was worse than NHS national standards. It is well understood how these delays cause harm to patients, lengthen response times and delay ambulances needed in the community. However, staff were actively looking for improvements and short and long-term solutions, both internally and externally with system partners. Also, there were few delays in the decisions taken around onward patient care. The department had resolved several flow problems which were in its own control but was limited by external factors.
Some of the trust’s senior leadership team were not sufficiently visible and approachable for some staff to provide assurance and support, demonstrate recognition and awareness of the risks and struggles staff experienced.
Although leaders and teams identified and escalated relevant risks and issues and identified actions to reduce their impact, these did not always have the desired outcome in times of crisis.

However:

Staff understood how to protect patients from abuse and acted on any concerns. They recognised when abuse might be occurring and were trained in how to deal with their concerns to keep patients safe.
Staff kept detailed and comprehensive records of patients’ care and treatment. Records were clear, up to date, stored securely and easily available to staff providing care.
Patients had an assessment of their infection risk and other clinical risks on arrival at the department.
Leaders in the emergency department demonstrated the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were supportive, caring and approachable in the service for patients and staff.
Staff in the department felt respected, supported and valued by their colleagues. They were focused on the needs of patients receiving care. There were strong examples of staff feeling able to speak up and raise concerns without fear.
There were effective systems to recognise, report and understand performance, including a live dashboard available to staff to be able to track performance.

Areas for improvement

We found areas for improvement including six breaches of legal requirements the trust must put right. We found three further areas where the trust should make improvements to comply with a minor breach that did not justify regulatory action, to prevent beaching a legal requirement, or to improve service quality.

For more information, see the ‘Areas for improvement’ section of this report.

How we carried out the inspection

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Our rating of services improved. We rated it them as good because:

In urgent and emergency care staff complied with systems and processes designed to keep people safe from avoidable harm including the management of safeguarding risks. Records, incidents, infection control, and changing risks of patients, including those of a deteriorating patient, were managed well. We found that patients needs were met in relation to pain management, and services were planned and delivered in line with best practice. Staff understood their responsibilities to mental capacity, and spoke to patients with compassion, dignity and respect. Although the department was busy, there had been innovative changes to patient pathways and streaming since our last inspection. There were concerns over local operational leadership at the hospital.
In medical care staff understood how to protect patients from abuse, completed relevant risk assessments and kept clear and legible records of patient care. The service used audit processes to monitor patient outcomes and used this information to improve services. 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. The management of the service had improved since the last inspection.
Staff in surgical services understood how to protect patients from abuse and the service worked with other agencies to do so. Staff completed and updated risk assessments for each patient. The surgical division participated in both national and local audits to monitor people’s care and treatment outcomes and compare with other similar services. All staff were committed to providing excellent care to their patients. Quality improvement projects had helped to improve the service being delivered to patients, however some projects were in their infancy.
Staff in outpatients understood how to protect patients from abuse and there were clear processes for reporting safeguarding concerns. There were systems in place to manage maintenance of equipment and repair faults when identified. Staff kept appropriate records of patients care and treatment. The service made sure staff were competent for their roles. Patients were treated with compassion, kindness, dignity and respect throughout their visits to outpatient services. 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. Staff supported patients with additional needs such as patients living with dementia. 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.

However:

In the emergency department there was a continuing shortage of middle grade medical staff and heavy reliance on temporary staff. Also, the management of medicines could have been improved. We found the department was frequently crowded which meant that individual needs could not always be met. During busy times, we found that some patients felt their care was rushed. We found there was poor day-to-day operational oversight of the department. There was little engagement with patient groups.
Although the timeliness of some elements of care provision had improved, patients did not always receive care and treatment within an acceptable timeframe and in the right place. Patient’s dignity and privacy were not always maintained and patients who became agitated did not always receive compassionate care from nursing staff.
In medical care, systems and processes to keep people safe were not always followed in relation to infection control and medicines management and performance in national audits was variable and outcomes for stroke patients needed improvement. National targets for referral to treatment times were not met for most medical specialities. Risk management processes needed to be improved as risks were not always graded, mitigated and reviewed appropriately
Although we found the surgical service had improved, the division still needed time to embed processes and practice, and improve certain areas, under new leadership. Medical gas oxygen cylinders were not being stored securely across surgical wards and theatres. Staff required some additional support to manage patients living with mental health needs safely. Staffing on wards was regularly at minimum staffing levels rather than at funded establishment, particularly at night times. A shortage of radiologists made it difficult to provide 24-hour cover. Staff demonstrated a limited understanding of the Mental Capacity Act. Systems used by the trust did not help promote flow and efficiency in theatres and risked the safety of patients.
Outpatient services were primarily a five-day service. The introduction of a new patient appointment booking system, had presented a number of difficulties in the delivery of services. 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.

We carried out an announced inspection 24-27 January 2017 and an unannounced inspection at Gloucestershire Royal on 6 February 2017. This was a focused inspection to follow-up on concerns from a previous inspection. As such, not all domains were inspected in all core services.

The inspection team inspected the following seven core services at Gloucestershire Royal Hospital:

• Urgent and emergency services

• Medical care (including older people’s care)

• Surgery

• Maternity and gynaecology

• Services for children’s and young people

• End of life care

• Outpatients and diagnostic imaging

We did not inspect the critical care services (previously rated outstanding).

As we did not inspect all services we did not rate Gloucestershire Royal Hospital at this inspection.

Safe

We rated the safe domain as requires improvement in urgent and emergency services, medicine, surgery, maternity and gynaecology and also outpatients and diagnostic imaging. We rated it as good in children’s and young peoples and end of life services.

We had concerns about patient safety, particularly when the emergency department was crowded. Lack of patient flow within the hospital and in the wider community created a bottle neck in the emergency department, creating pressures in terms of space and staff capacity. This in turn increased the risk that patients may not be promptly assessed, diagnosed and treated.
Crowding was compounded by an acute shortage of staff. There was an acute shortage of middle grade doctors and there were particular concerns raised by medical and nursing staff about medical cover at night. Consultants regularly worked longer hours to support their junior colleagues and there were concerns about whether this could be sustained. Analysis of demand patterns indicated that more senior decision-makers were required at night. The department was not fully staffed with nurses. There were a significant number of nurse vacancies and heavy reliance on bank and agency staff to fill gaps in the rota. The department was not consistently staffed to planned levels, and when the department was crowded staff felt vulnerable because planned safe staff to patient ratios could not be maintained.
There was no senior (band seven) nurse employed to manage each shift as recommended by the National Institute for Health and Care Excellence (NICE).
Support staff functions were not adequately resourced. Healthcare assistants performed housekeeping duties, doctors, nurses and managers moved patients, and the nurse coordinator was frequently occupied with administrative duties.
Crowding in the emergency department meant that ambulance crews were frequently delayed in handing over their patients.
Patients were not always assessed quickly on their arrival in the emergency department. Initial assessment (triage) often consisted of a verbal handover from ambulance staff to the nurse coordinator without a face to face assessment of the patient.
Record keeping was generally poor and we could not be assured that patients received prompt and appropriate assessment, care and treatment. In particular, we were concerned about the recording of observations and the calculation of early warning scores. Patient observations were not always carried out consistently or early enough and early warning scores were not consistently calculated.
The mental health assessment room did not comply with safety standards recommended by the Royal College of Psychiatrists.
Within the medical service, not all specialties held regular and structured mortality and morbidity meetings to ensure learning could be identified and shared.
Staff did not always follow infection control procedures when entering wards and ensuring the cleanliness of equipment such as commodes.
Wards did not display evidence of when areas such as toilets were last cleaned and we did not see environmental audit result displayed on the wards we visited.
Staff did not always comply with legislation regarding the Control of Substances Hazardous to Health (COSHH).
The fabric of the building did not always ensure efficient cleaning could be carried out.
Daily checking of equipment such as resuscitation equipment was not carried out in all areas in line with the trust’s policy.
Medicines were not always managed correctly. Fridge temperatures were not monitored or actions taken where these fell out of normal range. There were a number of out of date patient group directives (PGD’s) in use in maternity services.
Records were not stored safely to ensure patient confidentiality was maintained at all times.
Staff did not always assess risks to patients and follow up with mitigating care interventions.
Nursing staffing levels were below establishment and wards, departments and operating theatres relied on bank and agency to cover shifts every day.
The trust did not use a recognised tool to assess the acuity of patients daily to ensure safe staffing levels were in place on each shift and particularly at night.
The number of surgical site infection rates for replacement hips and knees and spinal surgery had increased since our last inspection.
Mandatory training for all staff was not meeting the trust’s target.
The day unit was being used as an inpatient ward but domestic cover had not been set up for weekends to provide environmental cleaning or drinks to patients.
There was no cleaning carried out over the weekend in diagnostic imaging, and some outpatient treatment rooms and waiting areas were visibly dirty.
Staff were finding it difficult to trace patient notes since the introduction of a new computer system, and there was not a reliable system to track the numbers of temporary notes being used since its implementation. There were also some ongoing issues with allocation of baby NHS numbers and records migrating to the new system.
Some staff were unsure of their responsibilities in a resuscitation situation, and staff in ophthalmology did not know where to locate their nearest defibrillator.
In some areas, a systematic check of emergency resuscitation trolleys was not documented as having being carried out on a daily basis. There were no up to date Resuscitation Council (UK) guidelines available on the resuscitation trolleys. Intravenous fluids on the emergency resuscitation trolleys were not stored securely to ensure they were tamper evident.
Community midwives could not always print out clinical notes from the electronic system to go into women’s handheld notes. They also reported poor mobile phone coverage which meant there was sometimes a delay in getting messages.
Junior doctors in obstetrics did not attend skills drills training when they started at the trust though they did carry an emergency bleep and co0uld be the first to arrive in the delivery.
There were often long waiting times in the maternity triage area. Women were not seen within 15 minutes of attending the unit.
Consultant presence, on labour suite, was below the recommendations of the Royal College of Obstetricians and Gynaecologists (RCOG) Safer Childbirth (2007) guidance.
Not all outpatient waiting areas in the hospital had specific children’s areas. Areas that were not solely for children’s use in other parts of the hospital had waiting areas that were shared with adults.

However:

Staff understood their responsibilities to raise concerns and report incidents using the electronic reporting system. There was a culture of shared learning from incidents.
Staff spoke confidently about the duty of candour and gave examples of where it had been applied. Relevant staff had received training.
Most areas we visited were visibly clean and tidy. Staff were seen adhering to the trusts infection control policies including ‘bare below the elbows”.
There was a robust security system in place within the maternity unit, including locked doors, entry systems a baby security tagging system and CCTV.
There were systems in place for recognising and reporting safeguarding concerns. Staff were confident to raise any matters of concern and escalate them as appropriate.
There was good access to mandatory training within the maternity service, including skills drills training day and a one-day maternity update.
The development of a training package for midwives to enable them to administer flu vaccinations to at risk women had meant that a high number of women who would otherwise have not had the flu vaccine had received it.
The endoscopy unit had safe processes in place to ensure staff decontaminated and sterilised equipment in line with best practice.
Within the emergency department, there were hourly board rounds undertaken by senior clinicians in the department. This provided an overview of the department’s activity and provided an opportunity to identify and communicate safety concerns to the site and trust management teams. Patient safety checklists had been introduced, which provided a series of time-sequenced prompts. There was a well-structured medical staff handover where patients’ management plans and any safety concerns were discussed.

Effective

We rated the effective domain as good in urgent and emergency services, surgery and end of life. We rated it as requires improvement in medical care, We did not inspect this domain in maternity and gynaecology or children’s and young people’s services

People’s care and treatment was mostly planned and delivered in line with current evidence-based guidance and standards.
There was a range of recognised protocols and pathways in place and compliance with pathways and standards was frequently monitored through participation in national audits. Performance in national audits was mostly in line with other trusts nationally. There was evidence that audit was used to improve performance.
Within the emergency department, nursing and medical staff received regular teaching and clinical supervision. Staff were encouraged and supported to develop areas of interest in order to develop professionally and progress in their careers.
Care was delivered in a coordinated and multidisciplinary way.
The trust had been identified as a ‘mortality outlier’ in to relation reduction of fracture of bone (Upper/Lower limb)’ procedures, which included fractured hip. However, the actions had implemented had made improvements and these were ongoing at the time of our inspection.
Staff understood that end of life care could cover an extended period for example in the last year of life or patients and that patients benefited from early discussions and care planning.
End of life care was delivered with the principles of the Priorities for Care of the Dying Person set out by the Leadership Alliance for the Care of Dying Patient’s
Within end of life care, 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.

However:

Pain was not always promptly assessed and managed within the emergency department and we could not be assured that patients’ nutrition and hydration needs were consistently assessed or met.
The trust was not meeting the standard which requires the percentage of patients re-attending (unplanned) the department within seven days to be less than 5%.
The new computer system was causing issues for staff resulting in 'work around' processes to prevent any risks to patients.
Staff appraisals were not meeting the trust targets in all areas.
Theatre utilisation figures were low however; the trust was looking at ways of improving this.
Documentation relating to patients’ mental capacity and consent was not always complete or immediately obvious in ‘do not attempt cardio-pulmonary resuscitation’ (DNA CPR) records.
Explanations for the reason for the decision to withhold resuscitation attempts were not consistently clear. Records of resuscitation discussions with patients and their next of kin or of why decisions to withhold resuscitation attempts had been made were not always documented.
There was no organisational oversight of staff competency with regards to syringe driver training as records were not held centrally.
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.
The learning needs of all staff delivering end of life care were not identified.

Caring

We rated the caring domain as good in all the services this domain was inspected (urgent and emergency services, medical care and end of life services).

All of the patients we spoke with during our inspection commented very positively about the care they received from staff. This was consistent with the results of patient satisfaction surveys, which were mostly positive.
Patients were treated with compassion and kindness. We saw staff providing reassurance when patients were anxious or confused.
Patients were treated with courtesy, dignity and respect. We observed staff greeting patients and their relatives and introducing themselves by name and role.
Patients and their families were involved as partners in their care. They told us they were kept well informed about their care and treatment. We heard doctors and nurses explaining care and treatment in a sensitive and unhurried manner.
Staff took the time to interact with people who received end of life care and those people close to them in a respectful and considerate manner.
Staff and volunteers who worked with the department for spiritual support, bereavement officers and the mortuary were aware of and respectful of cultural and religious differences in end of life care.
Emotional support for patients and relatives was available through the in-patient and community specialist palliative care team, through clinical psychology, social worker, ward-based nurse specialists and end of life champions, the chaplaincy team and bereavement services.

However:

The discharge lounge was a mixed sex unit and did not have curtains to screen individual chairs and provide privacy for patients in their pyjamas or when assistance was needed with personal care needs.
Whilst responses to the friends and family test was positive, response rates were frequently low.

Responsive

We rated the responsive domain as requires improvement in urgent and emergency services, medicine, surgery and outpatients and diagnostic imaging. We rated it as good in end of life services.

The emergency department was consistently failing to meet the standard which requires that 95% of patients are discharged, admitted or transferred within four hours of arrival at the emergency department.
Patients frequently spent too long in the emergency department because they were waiting for an inpatient bed to become available. Lack of patient flow within the hospital and in the wider community created a bottleneck in the emergency department, causing crowding.
Crowding meant patients frequently queued in the corridor, where they were afforded little comfort or privacy. When the department became congested, relatives had to stand because there was insufficient seating.
Patients with mental health needs were not always promptly assessed or supported, particularly at night time when there was no mental health liaison service. Adolescents who had self-harmed did not receive a responsive service and were frequently inappropriately admitted while awaiting specialist assessment and support.
There was a lack of an appropriate welcoming space for patients with mental health needs.
The delivery of cardiology services did not meet the needs of the local population.
There were delays to discharges, which meant patient flow through the hospital was compromised.
There was a waiting list for patients requiring an endoscopic procedure.
The environment did not meet the needs of patients with dementia.
The trust reported 32 breaches of mixed sex accommodation in the period from January 2016 to October 2016 of which 11 were in the acute medical admissions unit.
The service was not always compliant with the accessible information standards and information leaflets were not readily available for patients for whom English was not their first language.
Due to pressure for beds and the demand on services, some patients had to use facilities and premises that were not always appropriate for inpatients. At times of high operational pressure patients were temporary admitted to endoscopy and medical day unit wards however, these were not identified as ‘escalation areas’ in the inpatient capacity protocol.
Elective operations were being cancelled due to the pressure on the beds within the trust and medical patients were being cared for on surgical wards to meet the demand.
Not all patients had their operations re-booked within the 28-day timescale.
Six patients had been waiting over 52 weeks for treatment, which is not acceptable.
The hospital was not meeting the 62 day target for cancer patients.
The diagnostic imaging department had a reporting backlog of 19,500 films and was not meeting its five day reporting target for accident and emergency x-rays.
A significant typing backlog was causing delays in sending out patient letters impacting on patient safety.
Implementation of new computer systems had impacted on waiting lists as some specialties could not see live waiting lists.
The trust was not meeting referral to treatment target in all specialities.
There were no designated beds for people receiving care at end of life. Side rooms were used when available but could not be guaranteed.
The percentage of patients dying in their preferred location and the percentage of patients discharged within 24 hours were not all known for all wards or hospital sites.
End of life complaints were not always handled promptly and in accordance with trust policy.

However:

The emergency and urgent care service had a number of admission avoidance initiatives in place to improve patient flow. These included the integrated discharge team who proactively identified and assessed appropriate patients who may be able to be supported in the community rather than admitted to the hospital.
We saw evidence that complaints were used to drive improvement.
The emergency department had recently developed a team known as the Gloucestershire elderly emergency care (GEEC), championed by an ED consultant. The aim was to raise awareness of the issues faced by frail elderly patients in the emergency department and to identify areas where the experience of this patient group could be improved.
Multi-agency management plans had been developed for patients with mental health needs who were frequent attenders in the ED. These enabled staff to better support patients and had resulted in a reduction of both ED attendances and admissions to hospital.
The trust’s referral to treatment time (RTT) for admitted pathways for medical services has been better than the England overall performance.
The average length of stay was for non-elective patients were better than the England average.
Staff in theatres and recovery had guidance in place to help reduce the anxiety of patients living with dementia when they using their services.
Rapid access assessment clinics were provided in some specialities, and some clinics were performing airway assessments via skype.
The hospital had introduced a new waiting list validation process to discharge patient’s ongoing follow up care to community based services such as GPs.
A project placing therapists on wards had helped increased patient discharges, and radiographers attended ward briefings to identify inpatients waiting for scans.
The in-patient specialist palliative care team was available to ward staff to provide advice and training regarding communication and end of life care; this included communicating with patients and carers.
The trust was one of two sites in the country which had been developing a medical examiner role and improved death certification process project since 2008. Benefits included better support for relatives over the explanation and causes of death as well as ensuring better oversight of signing of death certificates
The specialist palliative care team responded promptly to referrals, usually within one working day.

Well-led

We rated well-led domain as requires improvement in medical care and good in urgent and emergency care and end of life care.

There was a strong, cohesive and well-informed leadership team within the emergency and urgent care service who were highly visible and respected. The service had a detailed improvement plan in place with clear milestones and accountability for actions.
The emergency department produced high quality information which analysed demand capacity and patient flow, and was used to inform the improvement plan.
There were robust governance arrangements in place within the emergency and urgent care service. Clinical audit was well-managed and used to drive service improvement. Risks were understood, regularly discussed and actions taken to mitigate them.
There were cooperative and supportive relationships among staff. We observed exceptional teamwork, particularly when the emergency department was under pressure. Here, staff felt respected, valued and supported. Morale was mostly positive, although to an extent was undermined by workload pressures. Service improvement was everybody’s responsibility. Staff were encouraged and supported to undertake service improvement projects.
The leadership and culture of the specialist palliative care team in the trust reflected the vision and values of the trust. Leadership encouraged openness and transparency and promoted good quality care. There were leads on the wards for delivery of end of life care which supported the development of high quality end of life care.
The trust had a clear vision and strategy to deliver care at end of life linked to national best practice including Priorities for Care of the Dying Person set out by the Leadership Alliance for the Care of Dying Patient’s.
The governance framework for end of life care ensured that responsibilities were clear and that quality, performance and risks were understood and managed.
Staff felt respected and valued. There was a strong emphasis on promoting the safety and wellbeing of staff delivering end of life care in the community.
Services within specialist palliative and end of life care had been continuously improved and sustainability supported since the last inspection March 2015.

However:

Safety concerns which we identified at our last inspection had not been addressed, despite the introduction of new processes. Patient flow remained the major barrier to progress. The emergency department’s management team did not feel there was a culture of collective responsibility within the trust in relation to patient flow. There was frustration expressed that the emergency department bore a disproportionate level of risk, while the responsibility for the exit block sat with others. The emergency department was unable to influence the cultural shift which was required to address this significant barrier to improving patient flow and capacity.
Pressures faced by staff in the emergency department in relation to crowding were well understood and articulated by the management team but it did not appear that the risks relating to staff wellbeing, resilience and sustainability, had been widely shared or escalated within the organisation and they were not included on the department’s risk register.
There was a limited approach to obtaining the views of people who used the service. Workload pressures prevented opportunities for staff reflection or meaningful staff engagement and involvement in shaping the service.
There was no risk register specific to end of life care for the trust so there was no easy trust wide oversight of risk relating to the service.
There was a program of internal and national audits for end of life care, which were on time. However most local audit activity had not yet benefited from a thorough analysis of the data produced.

Within the medical service there was a lack of overview and governance around mortality and morbidity (M&M) meetings. Risks registered on the risk register were not always aligned with risks in the service.
There was a lack of understanding of the risk to safe patient care, the acuity of patients have on daily basis.

We saw several areas of outstanding practice including:

The diagnostic imaging department sent radiographers onto wards to liaise with staff to identify inpatients that were waiting for scans, in order to help speed up treatment and ultimately discharge.
The therapies department had placed occupational therapists and physiotherapists on wards over Christmas to support and speed up patient discharges during a period of high pressure.
The inpatient specialist palliative care team had won an annual staff award the trust - patient’s choice award 2016. This was from patients and others who recognised the NHS staff who had made a difference to their lives.
The consultant in the end of life care team was part of a multi-disciplinary team who had won the national Linda McEnhill award 2016. The award was recognition by the Palliative Care of People with Learning Disabilities professional network of excellence in end of life care for individuals with learning disabilities. Work included improving how different teams worked better together.
The development of a training package for midwives to enable them to administer flu vaccinations to at risk women had meant that a high number of women who would otherwise have not had the flu vaccine had received it.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

Review processes to monitor the acuity of patients to ensure safe staffing levels.
Ensure wards are compliant with legislation regarding the Control of Substances Hazardous to Health (COSSH).
Review processes for ensuring effective cleaning of ward areas and equipment and patient waiting areas.
Review the governance and effectiveness of care and treatment through participation in national audits.
Ensure staffing levels meet the acuity of patients.
Ensure patient records are kept securely at all times.
Ensure equipment is replaced to ensure safe diagnosis and treatment.
Ensure the medical day unit is suitable for the delivery of care and protects patients dingy and confidentiality.
Ensure all staff are trained and understand their responsibilities in a resuscitation situation.
Ensure resuscitation equipment is readily available and accessible to staff.
Ensure steps are taken to reduce the current typing backlog in some specialities.
Ensure specialities have oversight of all of their waiting lists.
Ensure that all information related to patients’ mental capacity and consent for ‘Do Not Attempt Cardio-Pulmonary Resuscitation’ (DNA CPR) is available in patient records.
Ensure trust staff comply with all the requirements of the Mental Capacity Act (2005).
Ensure the emergency department is consistently staffed to planned levels to deliver safe, effective and responsive care.
Review support staff functions to ensure the emergency department is adequately supported.
Ensure all staff are up-to-date with mandatory training.
Ensure patients arriving in the emergency department receive a prompt face-to-face assessment by a suitably qualified clinician.
Improve record keeping so that patients’ records provide a contemporaneous account of assessment, care and treatment.
Ensure patients in the emergency department receive prompt and regular observations and that early warning scores are calculated, recorded and acted upon.
Ensure the mental health assessment room in the emergency department meets safety standards recommended by the Royal College of Psychiatrists.
When using the day surgery unit for inpatients, provision must be made for the cleaning of the units at weekends and to provide patients with clean water jugs and drinks.
Ensure emergency resuscitation trolleys are checked and have guidelines attached according to best practice guidance and in line with trust policy.
Ensure the safe management of medicines at all times, including storage, use and disposal and the checking and signed for controlled drugs. Ensure all drug storage refrigerator temperatures are checked and the results recorded daily. Additionally if the temperatures fall outside of the accepted range action is taken and that action recorded.
Ensure patient group directives are up to date and consistent in their information.
Ensure women attending the triage unit within the maternity service are seen within 15 minutes of arrival.

In addition the trust should:

Ensure all staff are compliant with efficient decontamination of hands on entering wards.
The medical service should collect information about mortality and morbidity (M&M) meetings electronically across all services to ensure an audit trail is maintained and outputs governed.
Ensure emergency equipment (including resuscitation trolleys) is checked daily in line with trust policy and national guidance.
Review processes to recognise and respond to blank boxes on prescription charts to make sure patients receive medicines as prescribed.
Review the process to assess risks to patients and ensure a management plan is in place.
Review process to comply with VTE assessment in line with trust policy and national guidelines.
Ensure treatment pathways are reviewed and update to ensure best evidence-based treatment.
Ensure all staff receive yearly appraisals in line with trust policy.
Review process to ensure patients are reviewed by a consultant within 14 hours of admission in line with the London Quality Standards (2013).
Review processes to ensure compliance with the accessible information standards.
Ensure areas used to admit patients in times of high organisational pressures are suitable and staffed to ensure safe care and treatment of patients.
Ensure effective monitoring of clinical improvement and audits, including compliance with accurate and timely NEWS assessments.
Ensure timely response to complaints in line with trust policy.
Ensure there are sufficient numbers of staff with appropriate skills and experience on each shift in diagnostic imaging.
Ensure identification procedures in diagnostic imaging are robust and recorded.
Ensure all staff are up to date with mandatory training.
Ensure all patient’s referral to treatment times do not exceed national targets including cancer wait targets.
Ensure steps are taken to reduce the current reporting backlog.
Ensure diagnostic imaging examinations are reported within target for the accident and emergency department.
Ensure steps are taken to monitor and reduce the numbers of temporary notes in use.
Ensure all hazardous chemicals and cleaning products are securely stored.
Review facilities for staff to take breaks and make drinks away from clinical areas
Ensure staff can effectively trace patient records through the hospital.
Ensure disabled toilets have sufficient alarm systems.
Ensure all risk identified relating to the provision of end of life care is included on a risk register.
Ensure the training needs analysis for general staff on wards related to end of life care is completed by the trust end of life care quality group
Consider involving specialist palliative care team and support teams in major incident plan practices or exercises.
Review the signage and consider if the system of using ‘white rose’ symbols to assist location of trust mortuaries is effective
Ensure specialist palliative care team are able to use the results of the safety thermometer information in relation to patients receiving end of life care.
Continue to work in collaboration with partners and stakeholders in its catchment area to improve patient flow within the whole system, thereby taking pressure off the emergency department, reducing crowding and the length of time patients spend in the department.
Ensure the emergency department is supported by the wider hospital and that there is more engagement from specialties in addressing the risks associated with patient flow.
Ensure the workload pressures and impact on staff wellbeing, associated with crowding in the emergency department, are understood, identified on the risk register and that staff are supported as appropriate.
Ensure all staff within the specialities is aware of Never Events and the learning needed to prevent a reoccurrence.
Continue to make improvements with the reduction of surgical site infection rates.
Review the pre admission clinic area for comfort and suitability
Provide resuscitation equipment for the pre admission unit to ensure if a patient collapsed, they receive the correct care in a timely manner.
Review the equipment in the pre-admission unit to ensure it meets the needs of the service.
Patient group directions (PGDs) should be reviewed as they were out of date and the correct authorisation signatures should be included.
Continue to work on your action plan to address the shortfalls identified in the mortality outliers.
Review the lack of 24-hour emergency theatre to ensure no patients will be put at risk.
Continue to address issues resulting from the new computer system.
Improve the number of staff appraisals completed.
Reduce the number of patients who have their operation cancelled on the day of surgery, and reduce the number of patients not rebooked within 28 days.
Ensure emergency trolleys on the neonatal and children’s units have a system that easily highlights if an emergency trolley has been tampered with between routine checks.
Support all children’s services to contribute to infection prevention and control audits so that risk can be accurately assessed.
Consider options of protecting children’s safety when waiting for appointments in parts of the hospital that are not dedicated to paediatrics.
Continue with strategies to maintain staffing levels that meet national guidelines.
The trust should ensure electronic systems in place, especially for community midwives, enable them to input data in a timely way. Additionally they should have mobile phones with better connectivity to ensure they receive their messages in a timely way.
The trust should ensure that all inpatient venous thromboembolism (VTE) risk assessments are completed.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Gloucestershire Royal Hospital is one of two district general hospitals run by Gloucestershire Hospitals NHS Foundation Trust. It is an acute hospital with 683 beds. It provides urgent and emergency services, medical care, surgical care, critical care, maternity and gynaecology, services for children and young people, end of life care and outpatient and diagnostic imaging services. It provides specialist cancer care to patients from Gloucestershire, Worcestershire and Herefordshire as the hub for the three Counties’ Cancer Network

We inspected this trust as part of our in-depth hospital inspection programme. The trust was selected as it was an example of a low risk trust according to our new Intelligent Monitoring model. The inspection took place with an announced inspection 10–13 and an unannounced 20 March 2015.

Overall, Gloucestershire Royal Hospital was rated as requiring improvement. We rated it as good for caring and as requiring improvements in safety, effectiveness, being responsive to patients’ needs and being well-led. Overall, critical care was rated as outstanding. Maternity and gynaecology and services for children and young people were rated as good with the remaining core services rated as requiring improvement.

The trust’s services are managed through a divisional structure that covers all the hospitals within the trust, with some staff rotating between the three sites of Gloucestershire Royal Hospital, Cheltenham General Hospital and Stroud Maternity Hospital; therefore there are significant similarities between the content of the three location reports.

Our key findings were as follows:

Safe

Safety was judged as good in critical care and surgery, but in all other areas it required improvement.
The emergency department was frequently overcrowded; this was associated with a lack of patient flow, which in turn led to the risk that patients might not be promptly assessed, diagnosed and treated. Patients were not always cared for in the appropriate part of the department, with particular concerns about the safety of patients being cared for in the corridor when the department was so busy that it could not accommodate patients in clinical areas.
Staff were aware of how to report incidents and felt encouraged to do so. However, overall the trust was reporting fewer incidents than the national average (6.8 per 100 admissions compared with 9.3 per 100 admissions for the NHS England average in the period from November 2013 to October 2014).
The majority to staff stated they received feedback after reporting incidents. In all areas there were examples of learning from incidents.
Overall, the hospital was visibly clean; however some areas, such as the room for patients with mental health needs and areas in the medical wards, were found to be dusty, dirty and, or to contain litter. We also found a number of hand gel dispensers that were empty.
The number of cases of Clostridium difficile was significantly lower than in previous years, and at 34 cases up to February 2015 was well below the trust’s target of a maximum of 55 for the year ending April 2015. There had been just one case of methicillin-resistant Staphylococcus aureus (MRSA) in the year to date.

Throughout the hospital we found medication stored in resuscitation trolleys was not secured to demonstrate it had not been tampered with between checks.
- In some areas, records were not stored securely.
- Review of ‘do not attempt cardio-pulmonary resuscitation’ (DNA CPR) forms showed that the forms did not consistently demonstrate or link to a reference of patients’ mental capacity, and this information was not obvious or easily accessible in other records. Explanations for the reason for the decision to withhold resuscitation were not always clear, and records of discussions with patients and their next of kin, or of reasons why decisions to withhold resuscitation were not discussed, were always not documented.
- The majority of staff had attended safeguarding training in order to keep people safe from abuse. The exception to this was staff in urgent and emergency services, where for level 2 child protection training, particularly for junior doctors, completion rates were low, at 68% compared with the trust’s target of 90%.
- Staff had access to a range of mandatory training, and attendance was monitored. Records showed that the majority of staff had attended the required mandatory training, and the trust’s target of 90% was exceeded. However, in the unscheduled care division, medical staff were performing less well at accessing such training.
- Systems were in place to assess and respond to patient risk; these included risk assessments relevant to patients’ needs and early warning scoring systems to determine whether patients were at risk of deteriorating.
- The trust’s target for completion of venous thromboembolism (VTE) risk assessment had not being met since the first quarter of 2013/14.
- Nurse staffing levels had been reviewed and assessed, with oversees recruitment having taken place in order to meet the National Institute for Health and Care Excellence (NICE) Safe Staffing Guidance. Some areas, such as the flexible capacity wards, relied heavily on the use of bank and agency staff.
- Medical staffing was at safe levels in many services. However, there were some exceptions; these included consultants in acute medicine, general and old age medicine and radiology, and junior doctors in medicine and emergency care.
- The trust had a major incident and business continuity plan in place. The majority of staff were aware of their roles and responsibilities should the plan be activated.

Effective

Services were found to be effective in surgery, maternity and gynaecology, children and young people, end of life care and critical care. The latter we judged as outstanding. Improvements were required in urgent and emergency services and medicine.
In most services, people’s needs were assessed and care and treatment delivered in line with legislation, standards and evidence-based guidance.
Mortality rates were in line with those of other trusts, as measured by the Hospital Standardised Mortality Ratio.
Information about patient outcomes was routinely collected and monitored, with the trust participating in a number of national audits so it could benchmark its practice and performance against that of other trusts. In a number of these audits, the trust was performing less well than other trusts, for example the College of Emergency Medicine (CEM) audits, the National Sentinel Stroke Audits, The National Heart Failure Audit, and the Royal College of Physicians National Care of the Dying Audit 2104. Overall in surgery and critical care, the trust was performing better than the England average in most of the national audits it took part in.
Patient pain was assessed and well managed; the exception to this was in the emergency department, where not all patients had a pain score recorded and not all patients consistently received prompt pain relief.
In the ward areas, we found that patients had access to adequate food and fluids, observing that drinks were left within their reach.
Staff had access to training to develop their skills, knowledge and experience to deliver effective care and treatment. The trust’s target for the percentage of staff who had an annual appraisal was 90%, with the actual figure standing at 85%.
Multidisciplinary working was evident in all areas we inspected.
Overall patients were assessed in line with the Mental Capacity Act 2005 and care and treatment for patients unable to consent was undertaken in line with their best interest. However we did find one example where we were unable to find a documented assessment of a patient's capacity to make decisions despite evidence that this person was confused.
The hospital was working towards providing services seven days a week. The pharmacy service was open for limited hours on a Saturday and Sunday. Some on-call cover was provided at weekends by allied health care professionals. The palliative care team was available from 9am to 5pm Monday to Friday, with the specialist palliative care nurses providing an out-of-hours telephone advice service for clinicians.
Weekend ward rounds did not take place in some areas such as stroke, gastroenterology or the diabetes and endocrinology wards. In cardiology, a ward round took place on both days of the weekend.
Weekend discharges were problematic, with significantly fewer patients being discharged at this time.

Caring

Staff were providing kind and compassionate care with dignity and respect. Caring in critical care was outstanding, with all other areas rated as good.
In some areas such as the surgical admissions unit and outpatients, at times privacy could be compromised when personal conversations could be overheard and procedures seen.
Prior to the inspection we received a number of concerns from patients and relatives about a lack of clear communication; however, during the inspection we found that patients and, when appropriate, those close to them, were involved in decisions about patients’ care and treatment.
Patients generally received the support they needed to help them cope emotionally with their care, treatment and condition.
Spiritual support was available from within the hospital through the chaplaincy service, which provided a 24-hour on-call service.

Responsive

Urgent and emergency care and medicine required improvement; all other services were rated as good.
Bed occupancy at Gloucestershire Royal Hospital was constantly over 91%, which was above both the England average of 88% and the 85% level at which it is generally accepted that bed occupancy can start to affect the quality of care provided to patients and the orderly running of the hospital. The hospital had been operating at near 100% occupancy in the months leading up to the inspection.
There were issues with the flow of patients into, through and out of the hospital. The emergency department frequently became overcrowded when demand for services exceeded capacity. This was a hospital- and community-wide issue. In December 2014 and January 2015, the trust had declared an internal major incident when the situation became unmanageable.
The standard that requires 95% of patients to be discharged, admitted or transferred with four hours of arrival in A&E was consistently not being met. Trust wide performance was 82.86% with Gloucestershire Royal Hospital achieving 80.59%.
There were numerous examples of initiatives to reduce inappropriate emergency department attendances, to ensure patients were directed to the appropriate services to prevent admission and to shorten length of stay. Some of these were in their infancy and not yet fully developed to enable an effective and comprehensive service to be provided seven days a week.
The average length of stay for patients admitted as elective cases fell to its lowest level in February 2015; however this masked a performance that was better than the national average in surgery and worse than the national average in medicine. For non-elective patients, the average length of stay had risen to 6.7 days, which was above the trust’s target of 5.8 days for the third month in a row.
The number of emergency admissions within 30 days of discharge for both elective and emergency patients was above the trust’s target and had been for the last year.

The 18-week referral to treatment targets were being met in almost all surgical specialities. Urology and ophthalmology were just behind the 90% target at 85% and 87% respectively. The trust was below (that is worse than) the NHS England average 62-day cancer waiting time target.

The number of elective patients cancelled on the day of admission for a non-medical reason had not met the target in over a year, reaching its peak over the three months from December 2014 to February 2015, which matched the time during which the trust had been facing significant increased demand. This was also reflected in the number of patients who were cancelled and not rebooked within 28 days, which saw a significant rise in January 2015.
- There was an agreement with partners in the local health economy that the daily number of patients who were medically fit for discharge would not be more than 35 a day; this number had reached 74 in February 2015.
- The two-week wait target for urgent GP referrals for cancer and the 62-day wait from GP referral to treatment were not consistently being met. However, other targets such as the 31 days for surgery and radiotherapy were constantly met, as was the 31-day period from diagnosis to treatment.
- Systems were in place to identify patients who were living with dementia or who had a learning disability and might need additional support.
- Patients knew how to make a complaint if they wanted to, and information was available around the hospital outlining how to make a complaint and how it would be dealt with. There were examples of learning from complaints to improve care.

Well led

Leadership in critical care was rated as outstanding; surgery, maternity and gynaecology, children and young people, and outpatients were also well-led. Urgent and emergency care, medicine and end of life care all required improvement.
Most services had a five-year strategy in place. The exception to this was end of life care. Whilst the team demonstrated understanding of the national policy and priorities, there were no defined work plan priorities for Gloucestershire Royal Hospital for the present and future.
Staff were generally aware of the trust’s values of listening, helping, excelling, improving and uniting.
The trust was organised into four clinical divisions which operated across all trust sites; each was led by a chief of service, a divisional nursing director and a divisional operations director. This team was supported by a clinical director, a matron and a general manager in each specialty. Staff in all areas stated they felt supported by these lead staff. Of the executive directors, the director of nursing was singled out by many staff as visible and approachable.
Generally appropriate governance systems were in place; each specialty had governance meetings, and these were reported to the divisional governance meetings, with significant issues reported on to the trust’s quality governance meetings. Shortcomings were identified in two main areas. Monitoring of mortality and morbidity meetings in medicine was poor. We were informed these meetings took place, but we were not able to view any minutes of these meetings. In end of life care, governance and quality measurement were inconsistent. Whilst governance meetings were held, the minutes lacked details on information relating to actions planned or taken.
In the 2014 staff survey, the trust was performing less well than other trusts on staff engagement; however, there had been an improvement from the previous year. Many staff told us about the executive walk-arounds and the top 100 leaders’ information meetings.

We saw several areas of outstanding practice including:

Patients living with dementia on Ward 9b were able to take part in an activity group, which had been organised by one of the healthcare assistants. The activity group enabled the patients to become involved in activities and encouraged them to maintain their skills and independence. The group was held weekly, and patients were able to play bingo, watch films, take part in reminiscence, paint, sing and eat lunch together. Activities were tailored to individual preferences, and relatives were encouraged to be involved.

The trust had a mobile chemotherapy unit which enabled patients to receive chemotherapy treatment closer to their homes, to prevent frequent travel to hospital.

Patient record keeping in critical care was outstanding. All the patients’ records we saw were completed with high levels of detail. The records contained all the essential details to keep patients safe and ensure all staff working with them had the right information to provide safe care and treatment at all times.

There was an outstanding holistic and multidisciplinary approach to assessing and planning care in the department of critical care. All the staff involved with the patients worked with one another to ensure the care given to the patient followed an agreed treatment plan and team approach. Each aspect of the care and treatment had the patient at its centre.

In critical care, there was an outstanding commitment to education and training by both nurses and trainee doctors. Nurses and trainee doctors followed comprehensive induction programmes that were designed by experienced clinical staff over many years. All the staff we met who discussed their training and development spoke very highly of the programmes on offer and there being no barriers to continuous learning.

There was outstanding care for bereavement in critical care. All staff spoke highly of how they were enabled to care for and support patients and relatives at this time. Bereavement care had been created with input from patients, carers, relatives and friends, and staff were particularly proud of the positive impact it had on bereaved people and patients nearing or reaching the end of their life.

The outstanding arrangements for governance and performance management in critical care drove continuous improvement and reflected best practice. There was a serious commitment to leadership, governance and driving improvements through audits, reviews, and staff honesty and openness. All staff had a role to play in this area and understood and respected the importance of their work.

Mobility in labour was promoted with the Mums Up and Mobile (MUM) programme, which included wireless cardiotocography (CTG) monitoring across the whole of the delivery suite.

Importantly, the trust must:

Improve its performance in relation to the time patients spend in the emergency department to ensure that patients are assessed and treated within appropriate timescales.

Continue to take steps to ensure there are sufficient numbers of suitably qualified, skilled and experienced consultants and middle grade doctors to provide senior medical presence in the emergency department 24 hours a day, seven days a week, and to reduce reliance on locum medical staff.

Continue to reduce ambulance handover delays and take steps to ensure that patients arriving at the emergency department by ambulance do not have to queue in the corridor because there is no capacity to accommodate them in clinical areas.

Develop clear protocols with regard to the care of patients queuing in the corridor. This should include risk assessment and the identification of safe levels of staffing and competence of staff deployed to undertake this care.

Work with healthcare partners to ensure that patients with mental health needs who attend the emergency department out of hours receive prompt and effective support from appropriately trained mental health practitioners.

Take immediate steps to address infection control risks in the ambulatory emergency care unit.

Ensure that systems to safeguard children from abuse are strengthened by ensuring that children’s safeguarding assessments are consistently carried out, and safeguarding referral rates are audited to ensure they are appropriate.

Ensure that senior medical staff in the emergency department are trained in level 3 safeguarding.

Ensure that patients in the emergency department have an assessment of their pain and prompt pain relief administered when necessary.

Take steps to strengthen the audit process in the emergency department to provide assurance that best (evidence-based) practice is consistently followed and actions continually improve patient outcomes.

Ensure minutes are kept of mortality and morbidity meetings in medicine so that care is assessed and monitored appropriately, lessons learnt and actions taken and recorded.

Ensure that patients’ records across the hospital are stored securely to prevent unauthorised access.

Ensure that the premises for the medical day unit are suitable to protect patients’ privacy, dignity and safety.

Ensure an effective system is in place in the medical wards to detect and control the spread of healthcare-associated infection.

Ensure patients’ mental capacity is clearly documented in relation to ‘do not attempt cardio-pulmonary resuscitation’ (DNA CPR) and ‘unwell/potentially deteriorating patient plan’ (UP) forms. Improvements in record keeping must include documented explanations of the reasoning behind decisions to withhold resuscitation, and documented discussions with patients and their next of kin, or reasons why decisions to withhold resuscitation were not discussed.

Ensure that where emergency equipment in the form of resuscitation trolleys is not available, the decision to not supply is based on a thorough risk assessment. Where emergency equipment is available, this should be ready to use at all times.

Review communication methods within maternity services to ensure sensitive and confidential information is appropriately stored and handled whilst being available to all appropriate staff providing care for the patient concerned.

Ensure that systems are in place to ensure that medication available in departments is in date and therefore safe to use.

In addition the trust should:

Review how staff perceive the feedback they get from incident reporting and the level of detail received.

Ensure that patients, including children, are adequately monitored in the emergency department waiting room to ensure that seriously unwell, anxious or deteriorating patients are identified and seen promptly.

Take steps to improve the experience for patients and visitors in the emergency department waiting room. This should include the provision of drinking water, a TV, and appropriate reading material and information about waiting times.

Review the emergency department nursing staff mix and training to ensure adequate numbers of staff are trained to identify, care for and treat seriously ill children.

Continue to improve hospital-wide ownership of the emergency department four-hour target, to ensure that delays in admission are minimised.

Reduce the number of patients who have their operation cancelled on the day of surgery, and reduce the number of patients not rebooked within 28 days.

Ensure all staff in surgery services are able to demonstrate and understanding of the requirements of the Mental Capacity Act and Deprivation of Liberty Safeguards, so patients are not put at unnecessary risk of staff not acting legally in their best interests. Ensure there is appropriate documentation in place to support decisions.

Ensure that the ambulatory emergency care unit is sited in an appropriately equipped area that is conducive to ensuring patients’ comfort and dignity.

Consider displaying feedback from patients and relatives for each individual medical ward.

Consider a system to identify when patient equipment has been cleaned.

Ensure all areas are clean and free from litter.

Store all medicines in critical care in a way that meets requirements for their security.

For safety of the medicines and equipment inside, ensure resuscitation trolleys are secured in such a way so there is clear evidence if they have been opened between checks.

Capture and report safety thermometer data in the department of critical care alongside the other data on patient harm that the department collects.

Ensure all items are within their expiry date.

Maintain continuity of care for patients on the day surgical unit to ensure they have their needs met 24 hours a day, seven days a week.

Review the medical and surgical cover at weekends for the day surgery unit to make sure patients are reviewed and discharges not held up.

Ensure patients who are admitted to the surgical day surgery unit can have their needs met by the staff team.

Reduce the number of times patients are moved between wards, for continuity of care.

Review the staffing levels of physiotherapists against the requirements of the Faculty of Intensive Care Medicine Core Standards.

Ensure the specialist palliative care team can be sustained and are able to remain responsive to the evidenced increased demands of complex referrals, provide a face-to-face seven-day service, provide ongoing staff training in line with national policy, and make improvements to inconsistent governance, risk management and quality measures.

Ensure that a strategy for end of life care is developed.

Ensure all patients who are referred by their GP with suspected cancer are seen with two weeks of referral, and treatment is started within 62 days of referral.

Ensure the cleaning arrangements for all outpatient areas are appropriate to maintain a high standard at all times.

Ensure that where medication is required to be stored at refrigeration temperatures, systems are in place to monitor the correct temperature.

Ensure that systems are in place in outpatients to identify in a timely manner and replace medication that is approaching its expiry date, to prevent potential harm to patients.

Ensure patients’ privacy and dignity is consistently respected in the outpatient department and medical unit.

Ensure patients in outpatients have access to information on the trust’s complaints procedure, and that this is readily available in all areas.

Ensure staffing levels and the skill mix of staff in the diagnostic and imaging teams meet the needs of patients at all times and support staff to deliver a quality service.

Review, in the maternity services, the midwifery and support staffing to ensure there are sufficient staff to meet patients’ needs at all times in all areas.

Ensure that in maternity services, both service risk registers detail actions underway to mitigate risks.

Review cleaning schedules in maternity services and devise systems to ensure staff know when equipment has been cleaned and is ready for use.

Within gynaecology, review recalibration schedules for weighing scales.

Within maternity services, review the provision of oxygen and air on resuscitaires to ensure that the correct gases are administered during resuscitation, in line with the Resuscitation Council guidelines.

Review the location of the maternity services’ registrar clinic and early pregnancy assessment clinic (at weekends) to ensure facilities are appropriate to provide care, assessment and treatment.

Review the processes to ensure early screening (pre 10 weeks’ gestation) can occur where the need for such screening is indicated.

Within maternity services, work with the wider organisation to ensure overall patient flow is effective to prevent the need for cancellation of gynaecology patients because of the need to accommodate other patients on Ward 2a.

Review the timeliness of access to patient information in alternative languages.

Ensure staff in all areas of maternity services are aware of the procedures to follow in the event of early discharge ahead of the completion of all bereavement processes.

Ensure all patients’ referral-to-treatment times do not exceed national targets, and that services are delivered in a way that focuses on patients’ holistic needs and does not mean patients experience long delays in receiving their first outpatient appointment.

Professor Sir Mike Richards, Chief Inspector of Hospitals

We carried out this inspection of the neonatal and paediatric services at Gloucester and Cheltenham hospitals in response to a request from the coroner's office. The coroner made this request because they had concerns about the service provided in both hospitals after the death of a baby at Cheltenham hospital in December 2010. We were asked to check if current arrangements at these hospitals were putting babies at risk.

We found that in 2011 the trust had re-structured the maternity services and all the neonatal and paediatric services had been moved to the Gloucester site. Cheltenham hospital now had a midwife led birthing centre for low risk births. During this inspection we visited the neonatal and paediatric units in Gloucester and the birthing centre in Cheltenham. We spoke with ten staff and five parents of babies who were being cared for in the units.

All parents we spoke with were very positive about their experience of the service. All staff we spoke with told us they felt supported to carry out their roles had had access to relevant training. There was evidence that learning from incidents took place and appropriate changes were implemented. Records were accurate and fit for purpose.

Overall we found that people who used the neonatal and paediatric services at Gloucester and Cheltenham hospitals received good care. We found no evidence to suggest that babies born in any of the units across both hospitals were being put at risk.

During our visit to Gloucester Royal Hospital we spent time on two General and Old Age Medicine (GOAM) wards and the discharge waiting area. We also looked at documentation for patients who were being discharged from four other wards. We spoke with 25 patients, four relatives and eight staff as well as observing staff interaction with patients.

We observed patients being treated with dignity and respect. Staff addressed patients by the name of their choice and we observed staff joking and laughing with patients in a friendly and respectful manner. Patients we spoke with told us staff treated them well. Patients told us 'I just can't fault it, they're ever so nice to me, it's like a little family, you get to know them and they get to know us' and 'It's better than a hotel in here, they can't do enough for you'.

All patients we spoke with told us they enjoyed the food. They told us 'I've had some excellent meals while I've been in here. I only tick the ones I like but they've been lovely' and 'The food just gets better and better'.'

We spoke with eight patients who were being discharged during the two days of our visit. Patients we spoke with who were being discharged spoke positively about how they had been informed of their discharge arrangements. One patient who was being discharged to a community hospital told us 'It's been very good here, everyone's really looked after me and they have arranged everything for me. I just have to wait for the ambulance'.

People that we spoke to were pleased with the treatment they had received. We received comments such as, "I have had excellent care", "I am being well looked after" and "I am being cared for very well". One person told us "I can get hold of a daily paper. A nurse will go or a bloke came round yesterday", and another said "a gentleman comes round to offer to get things from the shop. He got me some tissues and some bottled water yesterday".

People that we spoke to were positive about the food at the hospital. People made comments such as "The food is very good, I wouldn't fault it", "The food is ok, I have really enjoyed some meals" and "I have put on weight, I would like smaller meals".

People that we spoke to were pleased with the cleanliness of the hospital and told us "I cannot fault them for cleanliness", and "It is very clean. They clean every day". One person told us "I was pleasantly surprised by how clean it was".

People told us that were pleased with the staff that had treated them. One said, 'The staff are brilliant, excellent, really nice,' Another said, 'Staff are lovely and helpful, they put themselves out for you, and another said, 'They are kind on this ward and sit with patients as long as it takes'. One person told us 'They don't let you go home until you can cope'.

A number of people told us how busy the staff were with comments like, 'The staff are excellent. They are so busy; they don't always come when you call them,' 'The staff are alright. They are trying to do too many jobs at the same time,' and, 'Staff are lovely. They are very nice. They have a difficult job.'

Some people, particularly those who had been in the hospital for longer periods of time, told us that they were very bored, with little daytime activity. One person said, 'There's not much to do. I can't see the television and there are no papers,' and another said, 'There is no longer a newspaper trolley'. One person we spoke to said, 'I can't see a clock, so I don't know what time it is'

People were particularly positive about the food at the hospital, and we received comments such as, 'The food is good, they are big portions for me and I feel full up,' 'The food is excellent. When I came in I was not well enough to eat and now I am eating,' and 'I have put on weight in a week'. Another person said 'There is plenty to eat and drink'. One person told us that the food at the hospital has improved recently, saying, 'I was here six months ago and the food is better.' Some people had more mixed feelings and one said, 'The food is okay. You can't please everyone', while another told us 'I would not give it a star, perhaps half a star. I like plain meat and two veg so I have the same food every day, casserole. I don't like newer stuff like pasta.'

A number of people remarked on the cleanliness of the hospital. People gave us comments such as 'They are constantly cleaning here', 'The cleanliness is excellent; they move the beds to clean under them', and 'The cleanliness is excellent, really good. The curtains are cleaned and changed'

One person said 'It's been nice to meet you and be able to tell someone how good the place is'.

Gloucestershire Royal Hospital

All Inspections

20/09/2023

During an inspection looking at part of the service

26 April 2023

During an inspection looking at part of the service

13 April 2022

During a routine inspection

6 and 7 April 2022

During an inspection looking at part of the service

8 - 10 December 2021

During an inspection looking at part of the service

A summary of CQC findings on urgent and emergency care services in Gloucestershire

Summary of Gloucestershire Hospitals NHS Foundation Trust - Gloucester Royal Hospital

30 March 2021

During an inspection looking at part of the service

9th Oct to 12th Oct 2018

During a routine inspection

24-27/01/2017, 06/02/2017

During a routine inspection

10 March 2015

During an inspection of this service

10 - 13 March 2015, and 20 March 2015

During a routine inspection

29, 30 May 2013

During a routine inspection

5, 6 February 2013

During a routine inspection

4 August 2011

During an inspection looking at part of the service

3, 4 March 2011

During an inspection in response to concerns