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Provider: Gloucestershire Hospitals NHS Foundation Trust Requires improvement


Inspection carried out on 10 - 13 March 2015, and 20 March 2015

During a routine inspection

Gloucestershire Hospitals NHS Foundation Trust provides acute hospital services to a population of around 612,000 people in Gloucestershire and the surrounding areas.

The trust has three main locations that are registered with the Care Quality Commission (CQC), which are Gloucestershire Royal Hospital, Cheltenham General Hospital and Stroud Maternity Hospital. There are 1,072 beds across these three hospitals. The trust has six further locations registered at which the trust runs outpatient clinics and provides the imaging services. We did not visit these locations as part of this inspection.

We inspected this trust as part of our in-depth hospital inspection programme. The trust was selected as it is an example of a low risk trust according to our new intelligent monitoring model. It has been in the low risk group since March 2014. Our inspection was carried out in two parts: the announced visit, which took place on the 10–13 March 2015, and the unannounced visit, which took place during the evening of 20 March 2015.

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

Our key findings were as follows:

  • The hospitals in the trust were very busy. Bed occupancy was constantly over 91%, which is 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 a hospital. Gloucestershire Royal Hospital and Cheltenham General Hospital had been operating at near 100% occupancy in the months leading up to the inspection. This had placed significant pressures on the staff delivering the services and had impacted on the care, treatment and wellbeing of patients.

  • There were issues with the flow of patients into, through and out of the hospitals. 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%.

  • Every service was found to be caring. The inspection team found that staff across the organisation were highly committed to doing their best for patients. Staff were observed to be providing kind and compassionate care with dignity and respect. Caring in critical care was outstanding, with all other areas rated as good. Staff at all levels displayed a passion for delivering the best care possible and felt frustrated when they thought this was compromised by the pressures within Gloucestershire Royal Hospital and Cheltenham General Hospital and wider system.

  • In some areas, such as the surgical admissions unit and outpatients, at times privacy could be compromised when personal conversations could be overheard and procedures seen.

  • Prior to the inspection, we received details of a number of concerns from patients and relatives about a lack of clear communication; however, during the inspection we found that patients and, where appropriate, those close to them, were involved in decisions about 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 hospitals through the chaplaincy service, which provided a 24-hour on-call service.

  • Overall, the hospitals were clean; however, some areas needed attention. At Gloucestershire Royal Hospital, these included the room in the emergency department for patients with mental health needs. Some areas in the medical wards were found to be dusty, dirty and or to contain litter. We also found a number of hand gel dispensers that were empty. At Cheltenham General Hospital, building work in the imaging department was having an impact, with dust and dirt escaping into the corridor.

  • Across the trust, measures to deal with infection control were effective. The number of cases of Clostridium difficile had been significantly lower than in previous years, and at 34 cases up to February 2015 was well below the trust’s target of 55 for the year. There had been just one case of Methicillin Resistant Staphylococcus Aureus (MRSA) in the year to date. We saw that, with a few exceptions, staff were adhering to the trust’s infection control guidelines. At Stroud Maternity Hospital, infection control risks were not fully addressed, with no process in place to identify whether equipment had been cleaned and was ready for use.

  • Nursing 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.

  • In the ward areas, we found that patients had access to adequate food and fluids, observing that drinks were left within their reach.

  • In most services, people’s needs were assessed and care and treatment delivered in line with legislation, standards and evidence-based guidance.

  • 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 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.

  • Mortality rates were in line with those of other trusts as measured by the Hospital Standardised Mortality Ratio.

  • Patients’ pain was assessed and well managed; the exception to this was in the emergency department at Gloucestershire Royal Hospital and Cheltenham General Hospital, where not all patients had a pain score recorded and patients did not consistently receive prompt pain relief.

  • 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 hospitals were 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 healthcare professionals. The palliative care team were 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 discharged at this time.

  • The two-week wait 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 had a learning disability and who might need additional support.

We saw several areas of outstanding practice including:

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

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

  • Patient record keeping in critical care was outstanding. All the patient records we saw were completed with high levels of detail. There were 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 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 of 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 of 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 and support patients and relatives at this time. Bereavement care had been created with input from patients, carers, relatives and friends, and staff were particularly proud of the positive impact it had on bereaved people and patients nearing or reaching the end of their life.

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

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

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 that 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 at Gloucestershire Royal Hospital 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 departments 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 corridors in the emergency departments. 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 departments out of hours receive prompt and effective support from appropriately trained mental health practitioners.

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

  • Ensure that systems to safeguard children from abuse are strengthened 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 departments have an assessment of their pain and prompt pain relief administered when necessary.

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

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

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

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

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

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

  • 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 for decisions to withhold resuscitation, and documented discussions with patients and their next of kin, or reasons why decisions to withhold resuscitation were not discussed.

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

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

  • 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 all medication available is in date and therefore safe to use.

Professor Sir Mike Richards, Chief Inspector of Hospitals

CQC inspections of services

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.

Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.

Organisation Review of Compliance

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Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.

No reports of this type are available.

Other types of report

As well as standard inspection, intelligent monitoring and Mental Health Act Commissioner reports, there are other types of report that we have published under special circumstances.

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