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Tetbury Hospital Requires improvement


Inspection carried out on 13, 14, 21 September 2016

During a routine inspection

We carried out a comprehensive announced inspection of Tetbury Hospital as part of our programme of independent healthcare inspections under our new methodology. The inspection was carried out through announced visits on 13 and 14 September 2016 and an unannounced visit on 21 September 2016.

We inspected and reported on the following three core services:

  • Emergency and urgent care

  • Outpatients and diagnostic imaging

  • Urgent and emergency  services

Third party providers used some facilities at the hospital for example, Tetbury Hospital owned the X-ray equipment but did not perform or report on the X-rays. Other providers ran clinics from the outpatient and diagnostic imaging department and used the day surgery unit. We did not inspect their practice as part of this inspection.

Our key findings were as follows:

The overall rating for Tetbury Hospital was requires improvement.

Emergency and urgent care was rated as requires improvement overall. In the safe and effective domains it was rated as requires improvement and the caring, responsive and well led domains were rated as good.

Surgery was rated as good overall. The safe domain was rated as requires improvement and the caring, effective, responsive and well led domains were rated as good.

The outpatient and diagnostic imaging department was rated as good overall. In all domains except for effective the department was rated good. We do not rate effectiveness in outpatients and diagnostic imaging due to insufficient evidence being available.

Are services safe at this hospital?

We rated safety as requires improvement:

  • Cleaning schedules, fridge temperatures and daily checks of theatre equipment were not always recorded as complete.

  • Emergency drugs were not tamper-evident.

  • Patient allergies were not always recorded on prescription charts.

  • The hospital did not have a policy or guidance on quality standards for sepsis screening and management.

  • The hospital did not have a supply of blood products for use in an emergency.

  • There was poor compliance with some areas of mandatory training.

  • Safeguarding processes for children and young people attending the minor injury unit (MIU) were not robust. Emergency Nurse Practitioners were not adhering to the safeguarding arrangements in MIU, which required every child and young person to undergo a safeguarding assessment.

  • The resuscitation trolley and portable resuscitation equipment (grab bag) in MIU did not hold all the appropriate equipment for the resuscitation of children and young people.

  • Monthly hand hygiene audits were not completed regularly in MIU.


  • From April 2015 to March 2016 the hospital reported no never events, deaths or serious incidents. There were no cases of hospital-acquired infection.

  • Staff were clear about the process for reporting incidents and were encouraged to report incidents and concerns. There was evidence of learning and improvement following incidents.

  • Although the hospital did not provide specific training in the duty of candour staff were aware of the principles of this. They were open and honest and apologised to patients when things went wrong.

  • The hospital maintained good levels of cleanliness and hygiene and staff mostly took appropriate precautions to prevent and control the spread of infection. Staff were seen to adhere to the hospital’s cross infection policy

  • The hospital had a lead for safeguarding and from April 2015 to March 2016 the hospital reported no safeguarding incidents.

  • The hospital reported minimal use of agency staff and had a team of bank staff who already worked in the hospital to fill vacant shifts.

  • Sufficient staff were available to treat and care for patients who attended the MIU.

Are services effective at this hospital?

We rated effectiveness as requires improvement:

  • Analysis of national guideline updates did not always identify changes relevant to the hospital.

  • There were no mechanisms in place to ensure ready access to professional children’s nursing leadership within the service.

  • Competency assessments and peer review were not in place to support shared learning between staff on a continual basis.


  • Care and treatment was evidence-based and hospital policies followed guidance from the Department of Health and the National Institute for Health and Care Excellence (NICE).

  • New and updated policies and guidelines were discussed and approved at the monthly medical advisory committee (MAC) and the hospital quality committee (HQC) meetings.

  • The hospital had a low rate of unplanned transfers to other hospitals and from April 2015 to March 2016, there were no unplanned patient readmissions.

  • Staff received clinical supervision and all had appraisals completed within the last year. The hospital had systems to monitor and supervise staff.

  • The hospital collected information from patients on various aspects of their experience in the hospital and reported this annually.

  • The hospital monitored staff employed under practising privileges. There was an electronic system that flagged when appraisals or Disclosure and Barring Service (DBS) checks were due. These were up-to-date at the time of our inspection.

  • People’s consent to care and treatment was sought in line with legislation and guidance. Written consent was taken and forms were filed in patients’ records. Staff were knowledgeable about the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. The hospital provided training on these subjects.

  • There was good evidence of multidisciplinary working between staff in the hospital, GPs and outside organisations.

  • Parents said the management of their own and relatives’ pain in the MIU was effective. They praised the sensitivity of the Emergency Nurse Practitioners.

  • Staff actively involved patients, relatives, parents, children and young people in consent processes in MIU and outpatients.

Are services caring at this hospital?

We rated caring as good:

  • There was a high level of patient satisfaction with the service. All the feedback we received from patients regarding their care and treatment was positive and complimentary. The hospital had good results from the NHS Friends and Family Test.

  • We observed staff treating patients with kindness, dignity and respect.

  • Staff recognised when patients were anxious and provided them with reassurance.

  • Patients and their relatives or those close to them were encouraged to be involved in all stages of their treatment.

  • Parents said staff would go the “extra mile” to care for their relatives and they would highly recommend the MIU to their friends and family.

  • Patients and relatives said they were treated with dignity and respect in MIU and outpatients and they were always listened to and felt able to raise concerns.


  • There was a lack of privacy for patients when discussing their operation and condition.

  • The response rate to the NHS Friends and Family Test was low.

Are services responsive at this hospital?

We rated responsiveness as good:

  • Services were planned to meet the needs of the local population. They provided timely and convenient care to NHS and private patients.

  • Referral to treatment (RTT) times were consistently below (better than) the NHS England target.

  • Patients with complex needs were assessed and plans made for them prior to their admission. There was good access and facilities at the hospital for people with a disability. The hospital had a Dementia Strategy policy and a lead for dementia services. Staff also received training in dementia.

  • Staff managed admissions to reduce waiting times for patients.

  • The hospital had strict admission criteria. Staff were knowledgeable about this and knew when and how to take action if they were unsure whether a patient was suitable for a procedure at the hospital.

  • Clear information was provided to patients about how to make a complaint or raise a concern. The hospital received few complaints. The hospital took actions to resolve complaints and lessons were learned and shared with staff.

  • For the reporting period April 2016 to June 2016 following improvements to the triage arrangements, patients were triaged in the MIU within 15 minutes of arrival at reception.

  • A review of children and young people’s experiences of health services was captured as part of a service development review of Tetbury Hospital in 2016.

  • Staff were aware of the complaints policy and procedure and supported patients and relatives to raise issues and concerns.


  • There was no policy or lead for children and young people with a learning disability.

  • Feedback from parents, children and young people was not captured in the Tetbury Hospital patient survey and the friends and family test to support the development of child friendly services at the hospital.

  • There were limited printed information leaflets available about the care for children who had attended outpatients and the MIU. Information was not child friendly and often only given verbally.

Are services well-led at this hospital?

We rated well-led as good because:

  • The hospital had a clear vision and strategy and this was understood by staff. Staff were aware of the organisation’s values and the commitment to providing a quality and responsive service to patients.

  • There was an effective governance structure to support the delivery of good quality care. Staff were aware of their roles and responsibilities and what they were accountable for. There was a strong culture of delivering kind and compassionate patient-centred care.

  • We saw evidence of incidents and complaints discussed at governance meetings and information was shared at staff meetings.

  • Leaders were visible and approachable and had open door policies. Staff said leaders were accessible and they did not have any problems in raising concerns with them.

  • The hospital actively sought the views of patients, people close to them and staff about the service they provided. People were actively engaged and involved in decision-making.

  • Services which were not provided locally were identified and implemented at the hospital.


  • Not all risks were included in the hospital risk register including the lack of piped oxygen and blood supplies.

  • There were no mechanisms in place to ensure ready access to professional children’s nursing leadership within the service.

  • There was no nursing representation at board level or above matron level within the hospital

There were a number of areas where the provider needs to make improvements. Importantly, the provider must:

  • Adapt guidance for adults, children and young people on quality standards for sepsis screening and management.

  • Review oxygen provision to ensure patient risk is minimised.

  • Ensure theatre daily equipment checks are completed.

  • Ensure all emergency resuscitation drugs are tamper-evident.

  • Review their policies, processes and systems for obtaining blood products in an emergency.

  • Ensure robust safeguarding arrangements in line with hospital policy are in place for children and young people attending the minor injury unit (MIU).

  • Ensure all equipment in the MIU is in date and correctly labelled.

In addition the provider should:

  • Ensure all bins used for disposing of clinical waste are appropriate.

  • Review arrangements in respect of storing contaminated equipment for sterilisation.

  • Ensure patient allergies are recorded on prescription charts.

  • Consider following the guidance of the National Early Warning System (NEWS) to identify and respond to deteriorating patients.

  • Consider providing more privacy for patients when discussing their operation and condition.

  • Consider providing separate areas for male and female patients.

  • Develop a tool to obtain feedback from children, young people and their families.

  • Develop clinical outcomes and performance indicators patients attending the Minor Injuries Unit.

  • Ensure there are robust arrangements in place for the provision of professional children’s nursing leadership.

  • Take steps so that patients seated in minor injuries unit waiting areas can be observed by staff.

Ensure hand hygiene audits are completed monthly in MIU in line with hospital policy.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 5 June 2013

During a routine inspection

We previously visited this hospital in January 2013. At that time we were concerned that recruitment records did not provide assurance that workers, including volunteers, and medical practitioners working under practising privileges agreements, had undergone adequate vetting before they began working at Tetbury Hospital. This meant that people could not be assured that they received care and treatment from suitable individuals with appropriate skills and qualifications.

The hospital sent us a plan showing us what actions they would take in order to achieve compliance. We returned to check that improvements had been made.

We found that since our last visit the provider had audited all employment records to ensure that all relevant documents were in place and were up-to-date. We were satisfied that the provider had effective recruitment procedures in place and could demonstrate that people who used services were not cared for by unsuitable individuals.

Inspection carried out on 10 January 2013

During a routine inspection

We talked with patients about their experience and observed how patients were cared for. Patients were very positive about their experience at Tetbury Hospital. They appreciated the convenience of Tetbury Hospital and they spoke highly of the friendly and attentive staff. One person told us they had chosen to come to Tetbury Hospital because a friend had recommended it. They said "he couldn't speak highly enough of the surgeon". Another person, who had undergone surgery on the day of our visit described "a pleasant experience" and praised the staff for putting them at their ease. Patients told us that they were given information about their treatment and had opportunities to ask questions. They said that they felt well informed and able to make decisions about their treatment and did not feel rushed.

We looked at some patient records. The hospital had followed correct procedures in respect of gaining people's consent for treatment. There were strict guidelines and screening in place to ensure that risks associated with surgery were assessed and only those people who were assessed as low risk were treated at Tetbury Hospital. There were adequate arrangements in place to deal with foreseeable emergencies.

People spoke highly of the staff; however employment records, including those relating to medical staff, were incomplete.

The hospital had an effective complaints procedure and there was evidence that complaints were fully investigated and acted upon.

Inspection carried out on 24 January 2012

During a routine inspection

We visited Tetbury Hospital on 24 January 2012 and spent the day at the service. The majority of patients treated at Tetbury Hospital came through a contract that Tetbury Hospital had with local Gloucestershire NHS organisations.

We met and talked with a number of patients and visitors about their experience. The patients were visiting outpatients, having daycase surgical procedures, or attending the minor injuries clinic. We met and talked with members of staff and discussed their training and development. We inspected all areas of the hospital for cleanliness and infection control. We were accompanied on our inspection by the hospital manager and the matron.

We looked at how the hospital assessed and monitored the safety and quality of its service to patients through its governance system. We checked a number of patient records to ensure that patients were appropriately assessed against their needs, and had given valid consent. We ensured that the records were an accurate reflection of the care and treatment that the patient had received. We checked that all relevant but only necessary information was captured and complete.

Patients and visitors that we met and talked with told us that the staff were "very good, very caring, very attentive." People said "we can't fault this hospital" and "everything's been clearly explained." We were told that the nursing and healthcare staff were "so kind" and "polite and respectful".

People who came to Tetbury Hospital for care and treatment were treated with privacy, dignity and respect. People had their needs met by staff that were trained and experienced. The hospital had a programme of governance that assessed and monitored the quality of the service. The hospital was clean in most areas, but we found some parts of the hospital that were not getting regular attention to cleanliness. People were protected from the risks of infection.

We met and talked with the chair of the hospital trustees. The chair was not able to demonstrate that the board had due regard to equality, diversity and human rights when considering hospital policies and procedures.

Reports under our old system of regulation (including those from before CQC was created)