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Provider: Gloucestershire Hospitals NHS Foundation Trust Requires improvement

Reports


Inspection carried out on 24-27 January 2017, 6 February 2017

During a routine inspection

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

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

• Urgent and emergency services

• Medical care (including older people’s care)

• Surgery

• Maternity and gynaecology

• Services for children’s and young people

• End of life care

• Outpatients and diagnostic imaging

The following services were inspected at Cheltenham General Hospital

• Urgent and emergency services

• Medical care (including older people’s care)

• Surgery

• End of life care

• Outpatients and diagnostic imaging

As this was a focused inspection we did not inspect the critical care services at either location (previously rated outstanding) and did not inspect all domains within the core services covered. This also meant we were not able to rate the organisation overall at this inspection.

Safe

We rated the safe domain as requires improvement in urgent and emergency services, medicine, surgery, and outpatients and diagnostic imaging in both hospitals. In Gloucester Royal Hospital we rated the safe domain as requires improvement in maternity and gynaecology and good in children’s and young people’s services. We rated the safe domain as good for end of life services across both hospitals.

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

  • Not all outpatient waiting areas in the hospital had specific children’s areas. Areas that were not solely for children’s use in other parts of the hospital had waiting areas that were shared with adults.
  • The trust did not assess the acuity of patients daily to ensure safe staffing levels were in place on each shift and particularly at night.
  • 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 the never events and the learning from these.
  • Kemerton and Chedworth Suite was at times being used as an inpatient ward but domestic cover had not been set up for weekends to provide cleaning and drinks to patients

However:

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

Effective

Where inspected, all services were rated as good with the exception of medical care which was rated as requires improvement in both hospitals.

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

However:

  • Pain was not always promptly assessed and managed within the emergency department and we could not be assured that patients’ nutrition and hydration needs were consistently assessed or met.
  • The trust was not meeting the standard which requires the percentage of patients re-attending (unplanned) the department within seven days to be less than 5%.
  • The trust had been identified as a ‘mortality outlier’ in to relation reduction of fracture of bone (Upper/Lower limb)’ procedures, which included fractured hip. However, the actions had implemented had made improvements and these were ongoing at the time of our inspection.
  • The medical service did not consistently contribute to and review the effectiveness of care and treatment through participation in national audits.
  • The emergency theatre was only manned on site for 20 hours each day. The remaining four hours were covered by ‘on call’ staff, which potentially placed patients at risk.
  • Theatre utilisation figures were low however; the trust was looking at ways of improving this.
  • The new computer system was causing issues for staff resulting in work arounds to prevent any risks to patients.
  • Staff appraisals were not meeting the trust targets in all areas.
  • Documentation relating to patients’ mental capacity and consent was not always complete or immediately obvious in ‘do not attempt cardio-pulmonary resuscitation’ (DNA CPR) records.
  • Explanations for the reason for the decision to withhold resuscitation attempts were not consistently clear. Records of resuscitation discussions with patients and their next of kin, or of why decisions to withhold resuscitation attempts had been made were not always documented.
  • There was no organisational oversight of staff competency with regards to syringe driver training as records were not held centrally.
  • There was not a seven day face to face service provided by the in-patient and community end of life care team. The trust provided a face to face service 9-5 Monday to Friday. Out-of-hours there was a telephone advice line available 24 hours, 7 days a week for health care professionals.
  • The learning needs of all staff delivering end of life care were not identified.
  • Whilst in some cases the possibility of dying had been recognised and communicated clearly, decisions made and actions taken in accordance with the person’s needs and wishes, not all appropriate patients experienced this.

Caring

We rated caring as good in all services where we inspected this domain, across both hospitals.

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

However:

  • The discharge lounge was a mixed sex unit and did not have curtains to screen individual chairs and provide privacy for patients in their pyjamas or when assistance was needed with personal care needs.
  • Whilst responses to the friends and family test was positive, response rates were frequently low.
  • Information about patients was not always kept confidential.
  • The results from a patient-led assessment of the care environment demonstrated that privacy for patients was not always provided.

Responsive

We rated the responsive domain as requires improvement in all services where we inspected this domain with the exception of the end of life service which was rated as good across both hospitals.

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

However:

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

Well-led

We rated the well led domain as requires improvement in urgent and emergency care and medical care in Gloucestershire Royal Hospital and in medical care in Cheltenham General Hospital. Were inspected elsewhere, we rated the well led domain as good.

  • There was a strong, cohesive and well-informed leadership team within the emergency and urgent care service who were highly visible and respected. The service had a detailed improvement plan in place with clear milestones and accountability for actions. However, safety concerns which we identified at our last inspection had not been addressed, despite the introduction of new processes. Poor patient flow remained the major barrier to progress. The emergency department was unable to influence the cultural shift which was required to address this significant barrier to improving patient flow and capacity.
  • 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.
  • Pressures faced by staff in the emergency department in relation to crowding were well understood and articulated by the management team but it did not appear that the risks relating to staff wellbeing, resilience and sustainability, had been widely shared or escalated within the organisation and they were not included on the department’s risk register.
  • There was a limited approach to obtaining the views of people who used the service. Workload pressures prevented opportunities for staff reflection or meaningful staff engagement and involvement in shaping the service.
  • There was no risk register specific to end of life care for the trust so there was no easy trust wide oversight of risk relating to the service. There was a program of internal and national audits; however, these were behind schedule due to recent staff shortages within the team.

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

However:

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

We saw several areas of outstanding practice including:

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

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

Importantly, the trust must:

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

Professor Sir Mike Richards

Chief Inspector of Hospitals


CQC inspections of services

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

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.