You are here

Great Western Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 4 August 2017

We carried out an announced inspection between 21 and 23 March 2017 and an unannounced inspection at Great Western Hospital on 27 and 28 March 2017 and 3 April 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 six core services at Great Western Hospital:

  • Urgent and emergency services
  • Medical care (including older people’s care)
  • Surgery
  • Critical care
  • Services for children and young people
  • Outpatients and diagnostic imaging

We also inspected:

  • Urgent care services (provided as a community service).

We did not inspect end of life care or maternity and gynaecology services (previously rated good). We did not inspect the effective, caring or responsive domains for services for children and young people (previously rated good). The effective domain was inspected but not rated for outpatients and diagnostic imaging.

Overall we rated Great Western Hospitals NHS Foundation Trust as requires improvement.

Safe

We rated the safe domain as requires improvement overall. Urgent and emergency services, medical care, surgery, critical care, services for children and young people and outpatients and diagnostic imaging were all rated as requires improvement.

  • As a result of high demand we found the emergency department was frequently full, with patients in all cubicles and around the nurses’ station. There were occasions where the emergency department was deemed to be unsafe as a result of the number of patients within the department. However, this was improving. We also found that as a result of pressures for beds in surgery some patients had to use facilities which were not always suitable for recovering from their surgery.
  • Compliance with safe systems to ensure medicines were stored at the correct temperature  needed to be improved. Daily checks of medicines were not always completed in the emergency department or critical care. We found in medical care that some areas did not have regular temperature checks. This meant there was limited assurance that medicines were being stored within required temperature ranges to ensure they were fit for use.
  • The storage of medicines needed to be improved. In medical care we found that some of the storage shelves did not allow for stock rotation, which increased the risk of medicines being out of date. We also found in critical care that the fridges used to store medicines could not be locked. This meant that medicines could be removed without authorisation.
  • Equipment used was not always checked in line with guidance to ensure it was fit for purpose. Daily checks of emergency equipment did not always take place.  In services for children and young people that heated water blankets did not have expiry dates or water change dates recorded.
  • There were areas throughout the hospital which did not have sufficient numbers of suitably qualified staff on duty to keep people safe. This included the emergency department observation unit where we observed a patient walking out of the department without staff knowing. Within medical care and surgery, services for children and young people and critical care there were wards and theatres which went through periods of understaffing, which meant that staffing numbers did not always meet national guidelines. In medical care we found that ambulatory care was sometimes left with no staff in it for short periods of time due to lone working arrangements.
  • Mandatory training rates needed to be improved in the emergency department for medical staff, in medical care, outpatients and diagnostic imaging, critical care, and surgery. In services for children and young people all medical staff fell below trust targets for all mandatory training and paediatric basic life support training was below target in all staff groups.
  • Safeguarding practices needed to be improved in outpatients and diagnostic imaging and in services for children and young people. In outpatients and diagnostic imaging only 20% of medical and dental staff had completed level two safeguarding adults training against a trust target of 80%. In services for children and young people staff did not have ready access to relevant safeguarding information on a patient due a filing backlog.
  • The security and completeness of records needed to be improved. We found in medical care and critical care that patient records were not always stored securely. We also found that in critical care patient allergies and venous flushes were not always documented. In medical care we found that not all patient documentation was completed in full and handovers between wards was not consistency provided to a high standard. This meant that patients' full needs may not always be met.

However:

  • There was a positive incident reporting culture. Openness and transparency was encouraged. Opportunities for learning were sought when an incident occurred and learning was shared between teams. Where never events occurred in surgery we found they were investigated fully and actions had been taken to prevent them from happening again.
  • We found all areas within the hospital, with a few exceptions, were visibly clean and tidy. Staff  followed National Institute of Health and Care Excellence standards for hand hygiene and audit results were positive.
  • We found that staffing levels for both medical and nursing staff were in line with recommended guidance in the emergency department, and critical care. Within medical care there were sufficient doctors to provide safe care for patients.

  • Risks to people who use services were appropriately assessed in the emergency department where we found observations and treatment decisions were made in a timely way. We found that patients' records were legible, complete, up to date and accurate in the emergency department, surgery, and critical care.

Effective

We rated the effective domain as good overall. It was rated as good for urgent and emergency care, medical care, surgery, critical care. It was inspected but not rated for outpatients and diagnostic imaging.

  • In the emergency department, medical care, surgery, services for children and young people, critical care and outpatients and diagnostic imaging we found that patients' care and treatment were planned and delivered in line with guidance, standards, best practice and legislation. This included guidance from the National Institute of Care Excellence and the Royal College of Emergency Medicine.
  • Information about people’s care and treatment was routinely monitored and action was taken to improve the effectiveness of treatment where shortfalls had been identified. In surgery the trust had a better rate for re-admission compared to the national average. The emergency department performed well in the latest Royal College of Emergency Medicine audits. In services for children and young people outcomes were either in line with or better than the national average.
  • Staff had the skills required to carry out their roles effectively. In all services we inspected we found that staff had qualifications, experience and had received competency training in line with their role requirements. Most services performed better than the trust target for completion of appraisals.
  • Patients received care and treatment from different disciplines who worked together in a coordinated way. All departments communicated well with each other to ensure effective treatment for patients. This multidisciplinary working approach continued over weekends where there were 24 hour diagnostics, critical care outreach, physiotherapy, pharmacy, and mental health liaison services.
  • Within all services we found that the nutrition and hydration needs of patients were fully assessed and that actions were taken to address concerns as soon as they were identified. Within the trauma unit innovative systems were in place to improve nutrition and hydration for patients.

However:

  • In some areas of the trust outcomes required improvement. In medical care areas of the national stroke audit, MINAP audit and the national heart failure audit required improvement.
  • In critical care the provision of therapy services did not meet national standards. We found there was insufficient access to physiotherapy and dietetic services.

Caring

We rated the caring domain as good overall. Medical care, surgery, critical care, outpatients and diagnostic imaging were rated good. Urgent and emergency care was rated outstanding.

  • In all areas feedback from patients was consistently positive. Patients, relatives and carers told inspectors they had received care that was compassionate, they had been involved as partners in care, and they were supported to cope emotionally with their care.
  • Inspectors observed patients being treated with kindness and respect and saw that patients and their relatives were active partners in their care. They were well informed of treatment options and were involved in decision making.
  • Emotional support was available to patients. Staff took time to sit with patients and talk to them. A psychiatric liaison nurse was available to provide psychological support. There were good examples of staff listening and acting supportively to patients suffering from emotional distress.

However:

  • Privacy and dignity was compromised in the discharge lounge, the surgical assessment unit, theatre recovery, and ophthalmology. Conversations with patients could be overheard in the discharge lounge

    and in the

     ophthalmology department. We found that in the surgical assessment unit, the discharge lounge and theatre recovery, privacy was difficult to maintain when a patient required the toilet or to use a bedpan.

Responsive

We rated the responsive domain as requires improvement overall. It was rated as requires improvement for urgent and emergency care, medical care, surgery and outpatients and diagnostic imaging. It was rated as good for critical care.

  • Patient flow through the hospital required improvement. The trust found it difficult to discharge patients from medical, surgical, and critical care services who required social care or patients who had a complex discharge.
  • This resulted in the emergency department regularly being full to capacity, which meant that patients could not be seen in a timely way for assessment or treatment. The emergency department regularly breached targets for time spent in the department, with most breaches being attributable to unavailability of beds in the hospital.
  • Although medical outliers were managed well, the number of them impacted on the number of elective operations which could take place.
  • Facilities were not always fit for purpose, as a result of the numbers of patients being treated at the hospital. The medical expected department was not always able to separate male and female patients, which compromised privacy and dignity. In the emergency department patients were regularly accommodated around the nursing station without screens to protect their dignity.
  • For three months out of the past 10 the trust was performing worse than the national standard for two week urgent cancer referrals There were a high number of patients waiting for non-cancer outpatient appointments, with the most in ophthalmology. There were also delays in sending out of letters to patients after their appointment.

  • In medical care and outpatients and diagnostic imaging translation services were available, but they were not always utilised. In medical care relatives were sometimes used to translate, which compromised confidentiality.

However:

  • A number of steps had been taken to improve patient flow. This included re-locating  the ambulatory care service to increase capacity and the introduction of the medical expected unit. There were also effective patient flow meetings to establish who could be discharged.
  • High numbers of patients were streamed from the emergency department to the urgent care centre.
  • Reasonable adjustments were made to support patients in vulnerable circumstances throughout the hospital. Staff had a good understanding of the adjustments needed to support people living with dementia and patients with learning disabilities.

Well Led

We rated the well led domain as requires improvement overall. It was rated as good for urgent and emergency care, medical care, critical care, and outpatients and diagnostic imaging. It was rated as requires improvement for surgery and services for children and young people.

  • Services for children and young people felt disconnected from the rest of the trust. The leadership had not been embedded locally and there was no representation of services for children and young people on the board.
  • Nurses in services for children and young people did not recognise the trust as a good place to work. We were told that they often had to work long hours without access to a drink and without having a break. Nurses did not know the strategy of the women’s and children’s division.
  • In the emergency department, and surgical services staff felt that the executive team was not visible enough and that attempts to engage with staff could be better.
  • In surgery there were areas where there was a lack of management oversight. Also, actions identified to mitigate risks on the risk register were not always effective.

However:

  • There was a clear vision and strategy within the services which was underpinned by realistic goals. This strategy was being acted upon with innovative workstreams through the emergency department, medical care, surgery, services for children and young people and outpatients and diagnostic imaging.
  • Governance functioned effectively in all of the core services we inspected and where reviews were underway (in services for children and young people), there were clear action plans.
  • Leaders of services throughout the organisation had a good understanding of the challenges in their departments and had the knowledge, skills and experience to lead effectively. Staff throughout the organisation spoke positively about their leaders and were confident to go to them if they had concerns or they required support.

We saw several areas of outstanding practice, including:

  • The work of the education lead in the emergency department to improve education through various initiatives and work steams, including improved appraisals, training as part of the governance days and introduction of structured workbooks and teaching sessions.
  • The understanding and involvement of patients and those close to them in the paediatric emergency department during triage. We observed that the nurse put the patient at ease and made sure that the process was explained in a compassionate way.
  • The understanding of the emergency department leadership team of performance, governance, risks and its impact on patient care.
  • The use of an emergency department monthly governance day to engage staff with governance and learning from incidents, concerns or near misses.
  • The use of social media in the emergency department to engage staff to be more engaged with governance, share learning and discuss concerns with senior members of staff.
  • The work of the clinical trials team in the emergency department to increase trial recruitment from very few patients a year to several hundred patients a year and the impact this has had on patient experience in the department.
  • The medical care and outpatients services had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicine.
  • The medical care and outpatients services had introduced digital technology for patients living with dementia, which enabled them to access personalised reminiscence material.
  • The trauma unit within surgery provided a picture menu which showed photographs of all food options that the hospital provided. This could be used for non-verbal patients or patients with learning disabilities so they could more easily identify what food they would like at mealtimes. This had been hugely successful on the ward and at the time of the inspection this was being rolled out across the hospital.
  • The trust had introduced acute neurology clinics, located close to the short stay/ambulatory care unit, for patients who attended the acute medical unit and would have needed to be admitted in the past for further opinions and tests. These patients could now be discharged with an appointment, either the following day or the day after. This initiative had led to a significant number of admissions being avoided and provided a positive experience for patients.
  • The cardiology department inserted the first four lead pacemaker for a patient in the world. The medical staff were monitoring the patient’s recovery and rehabilitation as part of an international research project to assess the advantages of the new technology.
  • A  GP was employed in ambulatory care four days a week. The purpose of this new position was to improve communication with GPs to ensure basic tests had been completed prior to the patient attending the ambulatory care unit. It was anticipated that this would help to increase the flow of patients through the department and prevent patients attending the unit unnecessarily.

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

Importantly, the trust must:

  • Ensure that the emergency department observation unit is sufficiently staffed to keep people safe.
  • Ensure that medical staff in the emergency department receive appropriate mandatory training to enable them to carry out the duties they are employed to perform.
  • Ensure that daily checks are conducted on resuscitation equipment and medicine fridges in the emergency department to assess that they are safe to use.
  • Continue to develop and initiate plans and work streams in line with the improvement plan to improve flow in the emergency department at pace to improve safety and patient flow in the department.
  • Ensure the promotion and control of infection at all times and in all areas within medical care.
  • Ensure the security of patients’ confidential and personal information at all times within medical care.
  • Ensure the safety of patients at all times within medical care, including ensuring sufficient staff are on duty to monitor and provide care and treatment to patients. The trust should ensure patients are not left unattended in the ambulatory care department as a result of staff lone working.

  • Ensure that the privacy and dignity of patients in medical care is respected and ensure that breaches of the national mixed sex accommodation standard do not occur.
  • Ensure that staff in medical care consistently meet the trust target for mandatory training.
  • Ensure that handovers take place consistently in medical care when transferring patients between wards and departments. The trust should ensure that patients are assessed promptly by doctors following admission to the medical expected unit.
  • Ensure that there are clear pathways in medical care, including staffing levels, regarding the care of patients who require non-invasive ventilation (NIV).

  • Ensure nurse staffing levels on surgical wards meet expected standards as per hospital guidelines to keep patients safe.
  • Improve the number of staff on surgical wards who have completed all their mandatory training in line with the hospital target.
  • Improve access to patient toilet facilities within the surgical assessment unit and theatre recovery area.
  • Improve the response times to patients’ complaints within surgery.
  • Improve the timely completion of discharge letters to GP’s, including reducing the large backlog of letters which have not been sent within surgery.
  • Ensure that in critical care there are adequate allocated hours from allied healthcare professionals to meet national recommendations.
  • Ensure there are adequate numbers of suitably qualified, competent and skilled nursing and medical staff in areas where children are cared for, in line with national guidance.
  • Ensure all staff involved with the care of children are up-to-date with paediatric basic life support and mandatory training.
  • Ensure medical and dental staff in outpatients and diagnostic imaging have received training in level two safeguarding vulnerable adults.
  • Ensure medical and dental staff in outpatients and diagnostic imaging are up to date with mandatory training, including adult basic life support, fire training and paediatric life support

In addition the trust should:

  • Ensure that there are suitable quantities of cardiac monitors and trolleys in the emergency department to ensure that they keep people safe at times of crowding.
  • Ensure that alcohol and substance misuse support is available in the emergency department for patients who require it.
  • Ensure that the executive team is more engaged with staff in the emergency department and plan times of visits better to prevent a negative impact on staff morale.
  • Ensure that equipment used for personal care within medical care services is fit for purpose and that staff can provide assistance promptly if the patient becomes unwell while using equipment. This relates to showers which were not easily accessible.
  • Ensure that clinical equipment in medical care, such as needles and blades, is stored securely.
  • Ensure the safe storage of medicines, including creams and ointments at all times. This should include ensuring that medicines are stored in accordance with manufacturers' guidelines.
  • Ensure that where oxygen cylinders are stored in medical care, there is appropriate signage to inform staff and visitors to the area.
  • Ensure that staff working in all departments in medical care have access to emergency equipment and medicines in order to be able to respond promptly to medical emergencies.
  • Ensure within medical care that care documentation, including care plans, and risk assessments, are completed in sufficient detail to inform staff of the individualised care and treatment that is required for each patient.
  • Ensure that nursing staffing levels in medical care consistently meet the assessed and agreed staffing establishment for all wards and departments.
  • Ensure that within medical care performance against national audits is improved.
  • Ensure that within medical care patients' confidentiality is consistently respected when they require assistance with interpretation and/or translation.
  • Ensure that within medical care the complaints process is followed in a timely way and in accordance with the trust policy and procedure.
  • Ensure that staff within medical care are consistently informed and knowledgeable about the risk registers for their wards and departments.
  • Improve the completion of NEWS within surgery.
  • Improve referral to treatment time target compliance for surgical patients.
  • Ensure fabric curtains in critical care are replaced by disposable curtains to meet national standards.
  • Ensure there are processes to monitor and audit compliance with cleaning processes in critical care.
  • Ensure effective processes are put in place in critical care to learn from mortality and morbidity meetings.
  • Ensure staff in critical care check essential equipment daily in line with policy.
  • Ensure that in critical care, patients’ allergies are always documented and that staff sign for all medicines they administer.
  • Ensure the safe storage of medical gasses in critical care.
  • Ensure all patient medical records in critical care are stored securely.
  • Ensure practice guidance is regularly reviewed and updated in critical care to comply with national recommendations.
  • Review the training and competency assessment of medical staff in critical care to ensure there are always staff on duty that are competent in airway management.
  • Review nurses' paediatric competencies and training in critical care, to ensure they are up-to-date and current.
  • Explore the improvement of the patient toilet in critical care to include shower facilities so that these facilities are not shared with relatives.
  • Review the arrangement in critical care for the provision of follow-up clinics to ensure these are sustainable.
  • Ensure staff have access to appropriate equipment necessary in children’s services to carry out their roles and provide care effectively and efficiently.
  • Ensure all staff involved in the care and assessment of children and young people have safeguarding training in line with intercollegiate guidance.
  • Ensure that systems are in place to ensure case conference notes of vulnerable children are filed in their records in a timely manner.
  • Consider the wellbeing of staff within children’s and young people’s services in terms of regular access to rest breaks and hydration.
  • Consider mechanisms which could improve the connection of, and communication between, front line staff and divisional leaders within children’s and young people’s services.
  • Consider options for improving the connection between the women and children’s division and the rest of the trust, and review the representation of children’s services at board level.
  • Ensure patients within all of the diagnostic imaging waiting rooms can be monitored by staff.
  • Ensure that departments within outpatients have access to resuscitation equipment in line with hospital policy.
  • Provide patient information leaflets within departments in outpatients and diagnostic imaging that are available in different languages.
  • Ensure access for bariatric patients in outpatients is improved so patients can be assessed and treated without compromising their privacy.
  • Make improvements on the follow up backlog waiting list to meet people’s needs and minimise possible risk and harm caused to patients through excessive waits on outpatient appointments and excessive waits on the reporting of images.
  • Make improvements on the backlog in typing time times in outpatients and the delay in letters being sent to GPs.
  • Ensure arrangements are in place to replace aging diagnostic imaging equipment identified at risk of failure.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 4 August 2017

Effective

Good

Updated 4 August 2017

Caring

Good

Updated 4 August 2017

Responsive

Requires improvement

Updated 4 August 2017

Well-led

Requires improvement

Updated 4 August 2017

Checks on specific services

Maternity and gynaecology

Good

Updated 19 January 2016

Overall, we have judged the maternity and gynaecology services to be good for responsive, effective, caring and well-led services. Overall, we have judged safety in the maternity service requires improvement.

Care in both the gynaecology and maternity wards and central delivery suite was consultant led. Patients had risk assessments completed and reviewed regularly. There were established and thorough safeguarding procedures in place. Systems were in place which ensured women who required emergency obstetrics and gynaecology treatment and care were seen promptly by specialist nurses and consultants at all times. Clinical procedures were provided in line with national guidance and policy.

Safety improvements were required to the maternity services. The midwifery staffing levels did not comply with the Health and Social Care Act (2008) Code of Practice on staffing. The midwife to patient ratio exceeded (was worse than) recommended levels and one to one care for women in established labour was not achieved 100% of the time.

The maternity services were responsive to the needs of local women and those living outside of the locality of the hospital. The majority of patients were satisfied with the care and treatment they received and would recommend services. We saw records documenting patient’s choices and preferences. Additional specialist counselling was available to patients as required. Access and flow through the gynaecology inpatient service had been affected by intense trust wide service pressures.

At departmental levels there were effective, risk, quality and governance structures in place. Incidents, audits and other risk and quality measures were reviewed for service improvements and actions taken. Improvements were required to risk management processes at a senior level to ensure a complete overview of all serious issues and actions was maintained, and escalated to the board.

At departmental levels, systems were in place to effectively share information and learning. There was a positive culture and staff were proud of the patient care they provided and spoke of good and productive team working practices. Consultant, nursing and midwifery leadership was described as good, junior staff were well supported and departmental senior managers were visible and approachable. There was strong evidence from the midwives and consultant obstetricians of innovations completed to improve treatment, care and outcomes for patients.

Medical care (including older people’s care)

Requires improvement

Updated 4 August 2017

We rated this service as requires improvement because:

  • At times infection control was not managed well or promoted during the provision of care and treatment.
  • Not all clinical store cupboards were kept locked which meant a risk of visitors or patients accessing the areas. Clinical areas where medicines were stored were not monitored to ensure the temperature did not exceed the recommended limits.
  • Patients’ personal and confidential information was not stored securely in all areas. Not all documentation relating to patient care and treatment was completed in full which meant that staff were not fully informed of the actions they were to take to meet the patients' care and treatment needs.
  • Handovers did not consistently take place between wards and departments when transferring patients. This meant staff were not consistently provided with full and detailed information regarding  patients' identified care and treatment needs.
  • Patients were not consistently monitored in all departments. Staff told us that at times they were working alone in the ambulatory care department. This was due to staff needing to leave the department to deliver specimens to a collection point. Patients were sometimes left alone in the department which did not ensure their safety.
  • The staffing establishments were not consistently met on some wards due to high numbers of vacancies. The number of nursing staff on duty did not always meet national guidelines.
  • Staff within the unscheduled care division were not meeting the trust target for their mandatory training. This did not ensure staff were aware of the trust policies, procedures and systems.
  • The unscheduled care division participated in a programme of local and national audits. Some areas required improvements to meet the national average. For example, the national stroke audit, the national MINAP (heart attack) audit and the national heart failure audit.
  • Patients did not always receive the care they required seven days a week, for example, rehabilitation therapy was not available at the weekends.
  • Patients were able to be referred to the medical expected unit by their GP for assessment, care and treatment. At times patients had to wait for their treatment and physical tests to commence. There was no audit or monitoring to identify how long patients had to wait.
  • The privacy and dignity of patients who were admitted through the medical expected unit was not always met as both male and female patients shared accommodation. This is known as a mixed sex breach. At times confidential information regarding patients’ medical conditions was discussed in front of other patients. This did not ensure their privacy and dignity was fully respected.
  • Whilst staff had access to translation and interpretation services, at times the patients representatives were asked to support them. This did not ensure their confidentiality was protected and did not comply with national best practice guidelines.
  • Not all staff were aware of how to access, view or input into the risk registers for their wards or departments.

However:

  • Care and treatment was delivered in line with national legislation and recommendations. Staff were provided with up to date policies and procedures to inform them of the action they were required to take to meet the care needs of patients following recognised pathways. Between January and December 2016 the trust’s referral to treatment time (RTT) for admitted pathways for medicine had been better than the national average. The latest figures for December 2016 showed 94% of patients were treated within 18 weeks compared to the national average of 90%.
  • Staff were knowledgeable and competent to safeguard patients from abuse.
  • Patients received their care and treatment from staff who were kind, empathetic and showed understanding. The feedback from patients we spoke with regarding the services provided to them was consistently positive. We saw that staff strived to respect and promote the privacy and dignity of patients in their care. Patients and their representatives were included in discussions and decisions regarding their care and treatment.
  • The culture of the hospital was a positive learning environment and staff were encouraged and confident to report incidents to drive improvement.
  • The trust sought feedback from patients, visitors and staff to drive improvements.
  • The hospital environment generally appeared clean and hygienic.
  • There were sufficient numbers of medical staff, for example junior doctors, mid-grade doctors and consultants employed to meet the needs of the patients admitted through the unscheduled care division.
  • Information was shared at the start of shifts between doctors and nurses to ensure the imminent care and treatment needs of patients were met.
  • Multidisciplinary team working was apparent throughout the wards and departments to ensure the care and treatment needs of patients were met in a holistic way.
  • Services had been implemented and developed to meet the needs of local people. For example, the medical expected unit and ambulatory care.
  • The trust had a vision and strategy for the service and the unscheduled care management team were able to inform us of a number of work streams that were on-going to support this.
  • A risk assessment system was in place to improve the quality and safety of the care provided. Governance systems were in place to provide assurance that safe care was provided to a high standard.

Urgent and emergency services (A&E)

Requires improvement

Updated 4 August 2017

We rated this service as requires improvement because:

  • Patients experienced long delays in the emergency department. Four and 12 hour targets were consistently missed, with many breaches being attributable to patients waiting for either medical or surgical beds. Some patients were in the emergency department for over 30 hours, with 25% of patients being in the department for over 12 hours.
  • This was compounded by the lack of physical space within the department to accommodate  patients. There were regular occasions when there were over 35 patients in the 18 bedded majors’ area, which impacted how the needs of patients could be met.
  • Patients were frequently cared for in the corridor when there were no available cubicles. There was no privacy or dignity in this area and we saw regular nursing observations and blood tests being carried out in full view of other patients. Due to the location of this area by the doctors’ and nurses’ station, confidential conversations could easily be overheard and there was nowhere for relatives to sit.
  • Despite how busy the department was, we found that risks to patients were being assessed and managed by staff in the department. All of the patient records we looked at had risk assessments completed in full.
  • Staffing was not always sufficient in areas such as the emergency department observation unit. We found that staff in this area were managing too many competing priorities to care for their patients fully. This included tasks such as answering telephones.
  • Mandatory training rates for medical staff required improvement. Of the ten modules required for medical staff to complete none were above the trust target. This included paediatric life support.
  • Not all daily equipment and medications checks were completed. We found that on multiple occasions, daily checks of paediatric resuscitation equipment and medicines fridge temperatures were not completed.

However:

  • There was an active and positive culture of reporting incidents and near misses. Where incidents had occurred there was debriefing and learning was always sought. We were given examples where learning had changed practice.
  • Staffing numbers in the emergency department had increased. Additional nursing staff had been employed to manage risky areas such as the corridor and additional medical staff had been employed at night.
  • Care and treatment was delivered in line with best practice, legislation, guidance and standards. There was a multidisciplinary approach to achieving this in the emergency department, and in the wider hospital and health and social care community.
  • Staff had effective appraisals and supervision, including clinical supervision. All staff were given opportunities to develop and poor practice or concerns were quickly identified and rectified. There was a structured approach to ongoing education and development which responded to the needs of the department.
  • Feedback from patients was consistently positive about the way staff treated them. Staff were consistently compassionate towards their patients. Patients we spoke with and comment cards received were positive about the staff and recognised that staff made time to speak with them and to understand their needs.
  • The department had strong governance processes in place and a clear strategy, with quality and safety the top priorities.
  • The trust had taken significant steps to improve patient flow, including the relocation of the ambulatory care unit, the introduction of consultant of the day, and the introduction of a rapid discharge team. However, the impact of these initiatives continued to be impacted by continuing increasing demand for services.
  • The leaders within the emergency department were well respected and made a positive impact to morale within the department. Staff we spoke with were positive about the leadership team and recognised the challenges the department faced.

Surgery

Requires improvement

Updated 4 August 2017

​We rated this service as requires improvement because:

  • There had been two never events reported in surgery since our last inspection. These had been investigated and actions taken to prevent these happening again.
  • Due to pressure for beds and the demand for services, some patients had to use facilities and premises that were not always appropriate for inpatients.
  • Elective operations were being cancelled due to the pressure on the beds within the trust, and surgical wards were being used to accommodate medical patients.
  • Mandatory training compliance required improvement, particularly in basic life support and dementia awareness.
  • Some patients’ dignity was compromised by a lack of toilet facilities in the surgical assessment unit and theatre recovery.
  • Complaints were not always dealt with within 25 working days as per the hospital policy.

However:

  • The service encouraged openness and transparency from staff. Incident reporting, and incidents were viewed as a learning opportunity. Staff felt confident in raising concerns and reporting incidents.
  • Staff could demonstrate the patient outcomes were improving.
  • The trauma unit had used innovative ideas to improve nutrition and hydration for patients.
  • Patients living with dementia were well cared for on surgical wards.
  • There were improved governance arrangements across the surgical service, with a holistic view of care and performance across surgical services.

Intensive/critical care

Good

Updated 4 August 2017

​We rated this service as good because:

  • There was a good incident reporting culture, learning was identified and staff received feedback from incidents.
  • There were safe nursing and medical staffing levels to deliver effective care and treatment.
  • The service provided care and treatment in line with evidence-based guidance.
  • There were experienced nursing and medical staff who received annual appraisals and were supported with training and professional development.
  • The service monitored patient outcomes and these were good when compared nationally and to other similar units.
  • Staff cared for patients with compassion and kindness. Staff treated patients with respect and dignity at all times.
  • The provision of the service met the needs of most people.
  • Patients’ individual needs were met wherever possible.
  • There were clear governance and risk management processes.
  • There was strong leadership and teamwork.

However:

  • Provision for therapy services did not meet national guidelines. There was not sufficient physiotherapy and dietitian support, and limited support from other therapies.
  • There was a slightly higher than national average of delayed discharges for patients. However, this did not result in any significant delays in admitting new patients.
  • There was only one junior doctor in the unit at night, when standards recommended a unit of this size should be covered by two at all times.
  • Junior medical staff were not all ‘airway competent’ with skills in advanced airway techniques.
  • Patients were occasionally transferred to general wards at night, which was not optimal for their care.

Services for children & young people

Requires improvement

Updated 4 August 2017

This was a focused inspection to follow up on concerns from a previous inspection. We found the trust had not addressed all of the requirement notices from our inspection in 2015 and had not made improvements in the safe and well-led domains. These two domains have remained at requires improvement. Our inspection team only inspected the safe and well-led domains.

During this inspection we rated safe and well-led as requires improvement because:

  • Nursing staffing levels did not consistently meet recommended levels on the children’s unit or the special care baby unit. There were high levels of nursing vacancies.
  • The children’s service did not use an acuity assessment tool to help plan staffing levels.
  • Medical staff in children’s services failed to meet the targets for any mandatory training courses.
  • Out of hours medical cover was shared with numerous other areas of the hospital which meant the service did not always have the medical cover it needed to care for children as per Royal College of Paediatric and Child Health RCPCH recommended levels.
  • There was a lack of some basic equipment available to nurses on the children’s unit.
  • Numerous staff told us they were working for long periods without a break, or in some cases access to a drink.
  • The strategy for the women and children’s division was unknown to many of the staff who worked within it.
  • The women and children’s division felt disconnected with the rest of the hospital, and staff did not feel connected with their leaders. There was no paediatric representative at board level, which compounded this issue.

However:

  • We saw examples of positive learning from case reviews that were embedded in practice, and staff at all levels were aware of these.
  • There were creative initiatives in place such as consultant led simulation training which was well received by staff.
  • Staff understood their roles and responsibilities to safeguard children from potential risks or abuse and received supervision on a regular basis. The trust’s safeguarding teams worked with community and social care colleagues to identify and support children who may be at risk.

End of life care

Good

Updated 19 January 2016

We judged the overall service provision of end of life care as good. We found the service to be safe, effective, caring, responsive and well-led.

End of life care was seen as a priority for the trust. There was a clear overarching strategy for the service and plans to improve the delivery of care had already begun to take place with good results Education programmes had been developed and delivered, new documentation had been successfully introduced to the trust improving the pathway for patients although there was also some , yet to be fully embedded.

Staff, patients and relatives spoke in high regard for the specialist palliative care team; they were seen as responsive to the needs of both patients and staff. Out of hours there were good resources for staff to access including a 24 hour advice line managed by specialist palliative care nurses at a local hospice.

End of life care was responsive to the needs of patients and relatives. The end of life service was flexible and provided choice and accommodated individual needs for the patient and carers.

The specialist palliative care team had been involved in looking at complaints and incidents, as part of a wider team, and were keen to ensure training and teaching sessions were tailored and disseminated to ensure future complaints were minimised and care of patients was enhanced.

The specialist palliative care team were dedicated members of a cohesive team working to deliver effective care and treatment plans for patients, offering advice and acting as a resource for clinical teams.

Outpatients

Requires improvement

Updated 4 August 2017

We rated this service as requires improvement because:

  • Access to resuscitation equipment could be compromised due to the sharing of equipment between departments.
  • Within some departments people were waiting too long for appointments.

  • There were delays in the typing and sending of letters to GPs and the reporting on images.
  • Aging and failing equipment had resulted in lost clinic time and cancelled appointments.
  • Not all staff were up to date with mandatory training.
  • There was an inconsistent approach to the provision of clinical supervision and peer review.
  • Services were not always able to deliver and take account of the needs of different people.

However:

  • There was a good incident reporting culture where openness and transparency was encouraged.
  • There were clearly defined systems and processes to keep people safe and safeguarded from abuse.
  • People's care and treatment in both outpatients and diagnostic imaging was planned and delivered in line with current evidence based guidance, standards, best practice and legislation.
  • Staff worked effectively together in a coordinated way in the patients' best interests. There was clear evidence of multidisciplinary working within departments, the hospital, as well as other acute and community health services
  • Feedback from patients and relatives had been consistently positive. They praised the way the staff really understood their needs and treated them as individuals.
  • There was a clear statement of vision and values for each department and division, driven by quality and safety. It was translated into a credible strategy for outpatients with defined objectives that were regularly reviewed and relevant.
Other CQC inspections of services

Community & mental health inspection reports for Great Western Hospital can be found at Great Western Hospitals NHS Foundation Trust.