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Cheltenham General Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 19 June 2015

Cheltenham General Hospital is one of two district general hospitals run by Gloucestershire Hospitals NHS Foundation Trust. It is an acute hospital with 379 beds. It provides urgent and emergency services, medical care, surgical care, critical care, maternity and gynaecology, end of life care and outpatient and diagnostic and 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 on 10–13 and unannounced inspection 20 March 2015.

Overall, this 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 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, surgery and maternity, 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; however, some staff, for example, nurses in the emergency department and outpatient staff, reported that they did not receive feedback. In all areas there were examples of learning from incidents.
  • The trust had reported one Never Event in 2014 for interventional radiology, which was related to wrong-site surgery. (Never Events are serious, largely preventable patient safety incidents, which should not occur if the available preventative measures have been implemented.) This incident had been thoroughly investigated and an action plan was in place. This incident took place in one of the specialist theatres, and changes to practice had been made with the introduction of the World Health Organization (WHO) checklist in this area; however, no audit of the use of the checklist had been undertaken.
  • A further two Never Events had taken place in January 2015, which were still under investigation at the time of our inspection.
  • Overall, the hospital was visibly clean; however, there were some areas such as in the emergency department, where a toilet was not clean, and the waiting room was untidy at the end of the day. In the imaging department, where building work was taking place, dust and dirt were escaping into the corridor, and 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.
  • The number of cases of Clostridium difficile had been significantly lower than previous years, and at 34 cases up to February 2015 was well below the trust’s target maximum of 55 for the year. 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.
  • 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; this 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, 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.
  • 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.
  • 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 the 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 patient 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 Cheltenham General 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 trust was treating 74.7% of cancer patients within the 62-day target against the NHS England average of 81.2%.
  • 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 discharge would not be more than 35 a day; this 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, 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 Cheltenham General 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:

  • 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.

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

  • On the surgical division, we found the following outstanding practice: the trust had developed and printed its own style of controlled drugs register for patients’ own controlled drugs. Patents with ‘patients own controlled drugs’ were listed on a whiteboard on the controlled drugs cupboard door to help ensure patients took all their medicines home with them.

  • Medicines dispensed for an individual patient but not labelled for discharge had an additional yellow label attached stating, “NON-STOCK DO NOT SEND HOME WITH PATIENT”.

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

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.

  • Ensure that systems to safeguard children from abuse are strengthened and children’s safeguarding assessments are consistently carried out. There must be a process to ensure all appropriate child safeguarding referrals are made.

  • 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 the administration of eye drops complies with the relevant legislation.

  • 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 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.

  • 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 in the surgical division, when medicines are issued from wards or departments, the issued medicines comply with the relevant legislation and best practice.

  • Ensure that appropriate written consent is obtained prior to procedures being carried out in the outpatient department.

  • Ensure that all patients (men and women) are able to access the full range of tests in the urology outpatient department.

  • 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.

  • Identify suitable accommodation for the ambulatory emergency care unit and ensure that it is adequately staffed to provide a more comprehensive and effective service.

  • 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.

  • 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.

  • Record all controlled drugs in critical care in line with the trust’s policy.

  • capture and report safety thermometer data in the department of critical care alongside the other data on patient harm data 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 when it is open 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 security and safe storage of medicines, including medical gases.

  • Review the security of and records of equipment and medicines, including medical gases required for resuscitation and the treatment of anaphylaxis.

  • Review the security and safe storage of medicines, including medical gases in the mobile theatre.

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

  • Ensure that cleaning schedules in maternity services are reviewed and systems devised to ensure staff know when equipment has been cleaned and is ready for use.

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

  • Within maternity services, review the timeliness of access to patient information in alternative languages.

  • 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.

  • Ensure all outpatient departments provide sufficient facilities for disabled people, such as accessible toilet facilities.

  • Ensure staff promote the confidentiality of patients by ensuring conversations about patients cannot be overheard by other patients.

  • Ensure that the temperature of fridges used for the storage of medication and equipment can be checked daily.

  • Ensure that patients’ privacy and dignity are fully respected when patients are waiting for tests in public areas such as waiting rooms.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 19 June 2015

Effective

Requires improvement

Updated 19 June 2015

Caring

Good

Updated 19 June 2015

Responsive

Requires improvement

Updated 19 June 2015

Well-led

Requires improvement

Updated 19 June 2015

Checks on specific services

Maternity and gynaecology

Good

Updated 19 June 2015

There was a good culture of incident reporting, openness and learning, with good governance processes to support this. Women were provided with one-to-one care in labour, and patient risks were well managed. Care was delivered in line with national guidance in a caring and compassionate manner with high levels of patient satisfaction. The provision of gynaecological oncology services in Cheltenham General Hospital ensured timely access to ongoing oncology support and treatment. The maternity service meant women were able to have normal midwife-led care closer to their homes. The services were well-led by a long-established cohesive team.

However, there was no process to identify whether equipment had been cleaned and was ready for use, and medicines were not securely stored or held within tamper-evident containers.

Medical care

Requires improvement

Updated 19 June 2015

Medical care (including older people’s care)

Requires improvement

Updated 5 July 2017

We rated this service as requires improvement because:

  • The trust did not assess the acuity of patients daily to ensure safe staffing levels were in place on each shift, particularly at night. This was of concern in the coronary care unit.
  • The service did not consistenly participate in and review the effectiveness of treatment through national audits.
  • There were insufficient infection control and prevention facilities when entering and leaving some areas in wards and the cleanliness of equipment, such as commodes, was not always assured.
  • Staff did not always comply with legislation regarding the Control of Substances Hazardous to Health (COSHH).
  • Some areas were not fit for purpose and 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 line with the trust’s policy in all areas.
  • There were new machines for checking of patients’ blood sugar however, not all staff had had training so the old machines were also still in use. Staff did not always calibrate these daily in line with manufacturer’s guidance.
  • Fridge temperatures were not monitored consistently and medicines were not always stored correctly. Staff were unsure of when to dispose of some medicines in line with manufacturer’s recommendations.
  • Staff did not always comply with the trust policy and best practice when receiving controlled drugs from pharmacy.
  • Records were not stored safely to ensure patient confidentiality was maintained.
  • Nursing staffing levels were below establishment and wards relied on bank and agency to cover shifts every day.
  • 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.
  • 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.
  • There was not a systematic approach to mortality and morbidity (M&M) meetings. This meant there was a lack of overview and governance around mortality and morbidity (M&M) meetings.
  • There was a limited approach to obtaining the views of patients and their relatives.
  • The service had only made limited changes to improve treatment and care since our last inspection in 2015.
  • Risks on the risk register were not always aligned with risks in the service.

However:

  • Staff understood their responsibility to report incidents and there was evidence of learning from incidents across the organisation.
  • Staff were aware of their responsibilities for identifying and reporting safeguarding issues.
  • There were safe processes to review patients and ensure care and treatment plans were reviewed.
  • Ward staff in all areas we visited were seen to wear the correct uniform and use personal protective equipment, gloves and aprons as needed.
  • Patients were positive about the way they were treated and cared for in the medical wards.
  • We observed staff treated patients with kindness, dignity, respect and compassion.
  • There was a dedicated helpline for oncology and haematology patients. This enabled patients to be assessed and, if required (for example when neutropenic sepsis was suspected), admitted directly to Lillybrook ward without the need to go through the emergency department.
  • There was a competence training and assessment framework in place to ensure nurses were competent to carry out extended skills. Nurses were supported with revalidation processes.
  • The endoscopy unit had safe processes in place to ensure staff decontaminated and sterilised equipment in line with best practice. The endoscopy unit held join advisory group (JAG) accreditation and had procedures in place in line with the national safety standards for invasive procedures.
  • There was an effective framework for ‘board round’ and ward rounds which included input from staff from the multidisciplinary healthcare team.
  • Processes were in place to ensure consultants reviewed patients seven days a week. .
  • Staff were aware of mental capacity assessment and of deprivation of liberty safeguards applications.
  • The trust’s referral to treatment time (RTT) for admitted pathways for medical services had been better than the England overall performance.
  • Though information leaflets were not readily available for patients whose first language was not English, there was access to translation services Staff knew how to access this if needed.
  • Staff felt supported by managers and senior management felt assured by the new executive team.

Urgent and emergency services (A&E)

Requires improvement

Updated 5 July 2017

We have rated this service as requires improvement overall because:

  • The trust was not consistently meeting the national standard which requires that 95% of patients are discharged, admitted or transferred within four hours of arrival at the emergency department. A significant number of four hour breaches were attributed to a shortage of inpatient beds. The trust was not meeting the standard which requires that patients are reviewed by a doctor within one hour of arrival.
  • Patients were not consistently assessed promptly on arrival and in some cases a face-to-face assessment did not take place for some time. This meant there was a risk that seriously unwell or deteriorating patients may not be identified and managed promptly.
  • Some patients waited too long in the emergency department after the decision had been made to admit them to an inpatient bed. Patients regularly queued in the corridors in the emergency department and, despite the efforts of staff, patients’ comfort and dignity could not be maintained in the corridor.
  • Patients who attended the emergency department with mental health needs did not always access prompt assessment and support from mental health practitioners, particularly if they attended out of hours. There was not a designated mental health assessment room as recommended by the Royal College of Psychiatrists.
  • Compliance with mandatory training was variable so we could not be assured that all staff were familiar with safe systems, processes and practices.
  • 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.
  • 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.

However,

  • The emergency department was taking steps to mitigate the risks associated with crowding. Hourly board rounds conducted by senior clinicians provided an overview of activity and provided an opportunity to identify and communicate safety concerns to the site and trust management teams.
  • A patient safety checklist had been introduced, which provided a series of time-sequenced prompts for staff to undertake risk assessments, observations, tests and treatments, although audits showed that the use of this documentation was yet to be embedded in practice and was not consistently completed.
  • There were few serious incidents reported in urgent and emergency care. We saw good evidence that when incidents occurred, lessons were learned and improvements were made. There was openness and transparency about safety. Staff were familiar with their responsibilities under the Duty of Candour regulation.
  • There were effective processes in place for the identification and management of adults and children at risk of abuse and staff were familiar with these.
  • There was a range of recognised treatment protocols and care pathways. Compliance with pathways and standards was 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, for example in the treatment of sepsis.
  • 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 way with support from specialist teams and services such as the integrated discharge team.
  • 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 enable staff to better support patients and had resulted in a reduction of both ED attendances and admissions to hospital.
  • Complaints were listened to and acted upon. There was evidence that changes and improvements had been made in response to complaints.
  • 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. We heard doctors and nurses explaining care and treatment in a sensitive and unhurried manner.
  • There was a strong, cohesive and well informed management team who were highly visible and respected within the department.
  • There was an effective governance framework. Information was regularly monitored to provide a holistic understanding of performance, which included safety, quality and patient experience. Risks were understood, regularly discussed and actions taken to mitigate them.
  • The emergency department had developed an improvement plan with clear milestones and accountability for actions.
  • Staff morale was mainly positive, although this had been somewhat overshadowed by crowding and the pressures this placed on staff. Staff nevertheless felt valued and supported.
  • There were cooperative and supportive relationships among staff. We observed exceptional teamwork, particularly when the department was under pressure.
  • There was a strong focus on learning and improvement. Clinical audit was well managed and used to drive improvement, mistakes were openly discussed and learning acted upon. Staff at all levels were encouraged to play their part in improving patient experience.

Surgery

Updated 5 July 2017

We did not rate this service as we did not inspect all domains. However, we found:

  • Since our inspection in March 2015, the number of surgical site infection rates had increased for replacement hips. However this had improved at this inspection but for long bone reduction the number of surgical site infections was above the national average.
  • 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. Not all staff within these specialities were aware of these never events and the learning from them.
  • There were periods of understaffing on the surgical wards and operating theatres, where the trust’s planned staffing numbers of qualified nurses were not met.
  • Mandatory training for all staff was not meeting the trust’s target.
  • The surgical division was not meeting the trust’s target for staff appraisals.
  • 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 and staff were not aware of how to set up support services.
  • The trust had introduced a new computer system prior to our inspection that was causing some issues for staff resulting in work arounds to prevent any risks to patients.

However:

  • The service encouraged openness and transparency from staff with incident reporting, and incidents were viewed as a learning opportunity. Staff felt confident in raising concerns and reporting incidents.
  • 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 they had implemented had made improvements and these were ongoing at the time of our inspection. for example, in the 2016 hip fracture audit which had shown an improvement on 2015 audit
  • Training in safeguarding of adults and children had met the trust target for completion.

Intensive/critical care

Outstanding

Updated 19 June 2015

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

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

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

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

Some improvement was needed to ensure that one stock of a specific controlled drug was clear and that consumables were within their expiry date. The patient harm data was low, but the internal and external recording and display of some information could be improved.

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

The facilities in critical care were excellent for patients, visitors and staff, and met all the modern critical care building standards.

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

End of life care

Good

Updated 5 July 2017

We rated this service as Good because:

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

    life care 

    had been continuously improved and sustainability supported since the last inspection March 2015.

However:

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

Outpatients

Updated 5 July 2017

We did not rate this service as we did not inspect all domains. However, we found:

  • There were good infection control measures in place to help keep people safe, including hand hygiene practices, and the outpatient and diagnostic imaging departments had 100% compliance.

  • Patients who were vulnerable were protected from avoidable harm through comprehensive safeguarding procedures, and staff showed good understanding of these procedures and shared learning from safeguarding incidents.
  • Staff were given the right skills and training to do their jobs, and in ophthalmology a competency based training package had been developed for healthcare assistants.
  • Patients had access to specialist services, and the urology department had developed a dedicated consent form for cystoscopies and was expanding its one stop clinic service.
  • A new waiting list validation process had allowed some patients to be discharged back to primary medical care facilities for their ongoing care and follow up treatment.
  • Visually impaired patients were able to access services on an equal basis to others in ophthalmology through the use of colour coded signs, which made navigation of the department easier.
  • The oncology department provided an information presentation for all newly diagnosed patients which included opportunities to ask questions on a one to one basis.

However;

  • The service did not have sufficient arrangements to keep clinical and patient areas clean. Some treatment rooms in ophthalmology had carpet flooring and contained visibly dusty equipment, and the trust had not met its infection prevention and control training target.
  • The environment in the phlebotomy clinic was small and did not allow staff to respond to patients effectively if they became unwell..
  • The trust did not make sure staff had access to the most up to date policies and guidance, and had several versions of one Patient Group Directive (PGD) in circulation in ophthalmology.
  • The hospital was not meeting the 62 day waiting list target for cancer patients, and the trust was not meeting referral to treatment target in all specialities.
  • Patients were experiencing delays in diagnosis and treatment because 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, diagnosis and ongoing treatment.
  • Implementation of new IT systems had impacted on waiting lists as some specialties could not see their live waiting lists.
  • Patients were not able to easily access the top floor clinics in outpatients due to the lift being out of order.