Royal United Hospital Bath

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant people’s needs were not always met.

We have not awarded this service a score for Responsive.

Find out about when we will not publish a key question score and what we look at when we assess Responsive.

Description: We make sure people are at the centre of their care and treatment choices and we decide, in partnership with them, how to respond to any relevant changes in their needs.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

The service tailored its clinical assessments to the individual lives of its patients. For example, staff asked questions about home lives and personal circumstances, recording this social history in clinical files. We saw this in our review of patient records where individual home circumstances were always recorded. This meant treatment plans could be tailored to individual needs, such as if a person lived alone and required additional support on hospital discharge.

Staff told us they used tools to support patients with specific communication or cognitive needs. The department used ‘Hospital Passports’ and ‘This is me’ documents to support patients with dementia, a learning disability and autistic people. Although we could not review these during our inspection, the team explained they proactively requested this information from care or nursing homes to tailor their support to the individual. While the high-pressure environment sometimes limited their ability to complete new paperwork, staff prioritised obtaining existing records to bridge gaps in care.

Description: We understand the diverse health and care needs of people and our local communities, so care is joined-up, flexible and supports choice and continuity.

Quality Statement Score: 2

We scored the service as 2. The evidence showed some shortfalls. There were some shortfalls in how the service understood the diverse health and care needs of people and their local communities, so care was not always joined-up, flexible or supportive of choice and continuity.

The service had an above average number of patients leaving the department prior to being seen. Between April and September 2025, the number of patients who left the department before being seen started at 5.27% (456 patients) in April and peaked at 6.42% (568 patients) in July. While this dropped slightly to 4.59% in September, it remained above the national average of 2% to 3%. This meant staff had to spend time tracking down patients after they left, rather than focusing on treating them.

Disconnected computer systems undermined the department’s ability to coordinate safe, integrated care. Since the hospital’s electronic patient record (EPR) and mental health notes were on separate systems, emergency department (ED) clinicians could not access psychiatric histories. This gap was worsened by restricted service hours, such as the children and adolescent’s mental health team’s 3pm referral cut-off and the closure of Same Day Emergency Care (SDEC) on weekends. Consequently, the ED often had to act as a safety net for patients who did not require emergency intervention but had no available community or specialist alternative. The impact was a severely overcrowded environment where clinical staff had to manage a high volume of ‘stuck’ patients, stretching resources thin and compromising the safety and experience of everyone in the department.

Due to a lack of available ward beds, the department faced significant challenges in moving patients to the appropriate wards or social care settings. In late 2025, approximately 9.1% of patients remained in the department for over 12 hours. Although this performance was better than the national average (12.5%), these delays specifically affected elderly patients and those experiencing mental health distress. This mismatch between patient needs and hospital capacity meant the service fell short of the national goal to provide integrated, 24/7 mental health support and timely elderly care. The impact was a blocked system where patients had to stay in a loud, high-pressure environment longer than clinically necessary, increasing the risk of distress and physical deconditioning.

Description: We provide appropriate, accurate and up-to-date information in formats that we tailor to individual needs.

Quality Statement Score: 2

We scored the service as 2. The evidence showed some shortfalls. The service did not always supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The department did not always provide clear, automated information about waiting times and processes. Ongoing IT issues meant electronic screens in the waiting room only showed general community health adverts rather than wait times. We observed a receptionist hand-wrote a sign for 2 to 3 hours wait, but it was not clear to everyone in the room. This meant patients could not plan their stay or understand the pressure the department was under.

Patients told us the highest concern for them was being kept updated about what was happening to them. This was particularly with patients who were in waiting areas, as those in bays or treatment areas said staff were doing their best to keep them informed. A key theme in comments from people we spoke with (patients and family) was that they needed more information or at least to be acknowledged, even when there was nothing new to tell them.

Guidance provided to patients at the end of a visit to the service was inconsistent. For adult patients, staff told us they gave verbal advice or told them to look at the general NHS website. In contrast, the children’s department used QR codes to give parents easy access to discharge information. The lack of printed or digital summaries for adults meant patients might struggle to remember key medical advice once they returned home.

Staff said there were various ways in which they could provide information in a way people could understand. This included being able to provide interpretation for patients who did not speak English as a first language. They were also able to obtain support for people who were deaf and used British Sign Language. Teams used picture-based communication sheets to help patients with learning disabilities or language barriers.

Patients told us that although it was not explicitly said, they were confident staff would not share their confidential information with anyone not authorised to see it. Staff confirmed this and said this also included making sure they checked first with patients before giving information to family or friends, in case the patient did not want this information passed on at that time.

Description: We make it easy for people to share feedback and ideas or raise complaints about their care, treatment and support. We involve them in decisions about their care and tell them what’s changed as a result.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

Staff recognised how complaints were opportunities for learning and making things better for patients. They were discussed at governance meetings to look for themes and where improvement could be made. For example, the service acted quickly to improve how they supported neurodiverse patients based on direct feedback. When a formal complaint highlighted a lack of support for autistic patients, they responded by instructing reception staff to offer Autism Alert Cards and reinforced mandatory training for all patient-facing staff. This helped to ensure that staff adjusted their care to meet specific individual needs.

The service valued feedback as a tool for improvement, though it did not always make these processes visible to patients or staff. Staff viewed complaints as opportunities to improve clinical care. For example, they reviewed a case relating to a misdiagnosed injury to focus on root causes and make improvements in their care. Leaders also encouraged staff input through suggestion boxes and ‘You said, we did’ boards. However, during our visit, the feedback board was empty and patient resources, such as chaperone signage and patient feedback forms were stored out of sight. While the department used feedback to improve safety and clinical standards, the lack of visible information made it harder for patients to know how to share their experiences or understand their rights.

Description: We make sure that everyone can access the care, support and treatment they need when they need it.

Quality Statement Score: 1

We scored the service as 1. The evidence showed significant shortfalls. The service did not make sure that people could access the care, support and treatment they needed when they needed it.

The service struggled to provide timely care because the hospital consistently operated at full capacity, leading to severe overcrowding. On the 21 October 2025, which marked the first day of the inspection, a red flag was submitted regarding a critical incident. A red flag acts as early warning signal that a situation is developing which could lead to harm if not quickly addressed. This had resulted in a call for ward-based or specialty medical staff to prioritise seeing patients in the emergency department (ED) to make a clear decision about their onward care. Elective surgery was stood down in some circumstances. Wards were required to expedite discharges as early as possible and senior doctors supported decisions. The local system partners, on tactical calls, were asked to support the trust with prioritising discharges of patients and alternatives to admission. Leaders told us the hospital often ran at full capacity, meaning patients got stuck in the ED with nowhere to go. This was on their risk register and graded at the highest level of risk with a recognition of all the risk factors for patients.

The crowding and delays to ambulance handovers meant staff had no choice but to treat patients in corridors and other unsuitable areas. Patients also stayed for many hours and sometimes days in beds in busy areas. This was specifically for patients with mental ill health. Some majors’ patients were being cared for in the Urgent Treatment Centre (UTC) overnight as the majors’ area was also full. On the day before our visit, patients had stayed overnight in the Same Day Emergency Care (SDEC) area, which was not designed for patients to be accommodated overnight.

Patients often remained in ambulances because crews could not hand them over and return to the needs of the community quickly. To address this, there had been the introduction of the 45-minute handover standard operating procedure with the ambulance trust. This meant that any patient waiting with a crew for 45 minutes was automatically handed over to staff in the department. On the first day of our visit, the impact of this was evident with 13 patients remaining in the corridor at once, and trolleys blocking fire doors and emergency exits. Staff said patients were often held in the Pitstop rapid assessment and triage area, in the UTC, or in waiting areas, which increased the risk of harm to the patient as this was not an optimal place of safety.

There was action taken to divert patients to other services if they did not require urgent or emergency care, although the process was confusing and did not always manage patients’ expectations. National guidelines recommend triaging patients within 15 minutes of arrival, yet the trust averaged less than 60% compliance over the last year. On the first day of our visit, there was a period of confusion among staff where no one had been assigned to triage. When a member of staff did pick up the role, the longest wait for patients was 1 hour and 6 minutes and there were 11 patients waiting.

Staff said there was a process for other staff being brought to assist with triage when the waiting times grew, but one of the senior members of staff on duty admitted this was rarely adhered to and should the need for additional triage be recognised, it was often not supported.

The streaming process existed to direct walk-in patients to GPs or pharmacists, it was confusing. Patients were often moved to secondary waiting areas before being properly assessed, making it unclear when or how their clinical priority was decided. These delays and gaps in the assessment process meant the department did not have a reliable safety net. This increased the risk that a patient’s condition could worsen and go unnoticed.

There was no overnight service for patients needing treatment for minor injuries and minor illnesses as the service closed from 10pm to 8am. However, patients were still able to walk in as the waiting area was also the entrance for walk-in patients for the ED. Any patients who did arrive but did not need urgent or emergency care were streamed and either asked to make a GP appointment; go to their local pharmacy; given an appointment to come back to the service the next morning; or diverted if they were seriously unwell to the ED.

Adjacent services had been established to help reduce direct demand for urgent and emergency care. The hospital trust operated a medical and surgical same-day emergency care service (SDEC), along with a frailty acute same-day service which helped with the pressure on the ED.

A shortage of available ward beds prevented the department from admitting or discharging patients within required timeframes. The national goal was to treat, admit, or discharge 78% of patients within 4 hours. However, in the 2 weeks before our visit, only 18% to 39% of the most unwell patients met this standard. This was also reflected in a longer-term trend between October 2024 and September 2025, where the department averaged 59%, which was below the local and national averages for England (72%). While the service performed better than the national average for 12-hour waits, we still found patients waiting in chairs for over 16 hours due to communication errors. In July 2025, the proportion of patients who left the department (including those who left prior to assessment and those who left after assessment but before treatment was completed) peaked at 6.4%.

While the department showed significant year-on-year improvement and outperformed both local and national averages, extended waits remained a concern for some patients. Between October 2024 and September 2025, an average of 4.5% of patients waited more than 12 hours following a decision to admit. This was better than the England average of 11.3% for the same period. However, despite a steady reduction in these waits since early 2025, recent data indicated that numbers were beginning to rise again, mirroring a broader regional and national trend. During our inspection, we observed the human impact of these delays: one patient in the ambulatory care assessment unit had been waiting in a chair for over 16 hours due to a reported “miscommunication,” while another had been seated for 12 hours awaiting a medical assessment. Additionally, the longest wait for a patient yet to be assigned for an onward review was recorded at over 8 hours.

Ambulance handover delays and overcrowding prevented patients from accessing timely care, resulting in many people leaving without treatment. In the 10-month period from 1 October 2024 to 31 July 2025, 41% of patient handovers were delayed by more than 60 minutes. This was against an England average of 10.8%. During our visit, we observed elderly patients waiting in corridors for extended periods, including an 86-year-old who had been there for 7 hours, and an 80-year-old waiting for 6 hours. These wait times created an inequity in access, as the department’s most vulnerable patients had to wait in unsuitable, public areas.

Description: We actively seek out and listen to information about people who are most likely to experience inequality in experience or outcomes. We tailor the care, support and treatment in response to this.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

The trust had a co-produced ‘Vulnerable People Strategy’ to help ensure care meets the diverse and individual needs of people who may be vulnerable for a wide range of reasons, including but not limited to disability and neurodivergence. Evidence showed the service used tools like hospital passports and dementia safety matrices to provide person-centred care, and we were told the service had sensory items like fidget toys and iPads. Data received from the trust further informed their use of a network of ‘champions’. It stated the hospital had over 140 Learning Disability and Autism Champions, 100 Dementia Champions, and 60 Deaf Awareness Champions. They also introduced Makaton training at the beginning of 2025 which has resulted in 41 staff members, including nurses to domestic staff, to be able to communicate with non-verbal patients. Although we did not have the opportunity to see this in practice during our visit, staff told us they would escalate this need to their nurse in charge or matron.

The department was working to balance high patient demand across all ages, with opportunities to further strengthen the support for children and young people. Staff from the paediatric unit told us they were regularly moved to adult areas during busy periods. We were told staffing levels in the children’s area sometimes adjusted to a single nurse to meet this demand, which impacted on the speed of triage for children with minor injuries. This approach helped manage patient flow during these times, but it highlighted the impact of reduced staffing levels across the entire department.

Description: We support people to plan for important life changes, so they can have enough time to make informed decisions about their future, including at the end of their life.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

The department improved future planning by integrating specialist teams and involving families in the decision-making process. When patients could not speak for themselves, staff made documented efforts to engage with relatives and carers to understand the patient’s values. These proactive reviews caught vulnerable patients who might otherwise have been missed in the busy ED environment. By involving families and specialist nurses, the department ensured that even in high-pressure situations, the care provided remained person-centred and legally compliant with the Mental Capacity Act.

We saw records to alert staff to the wishes of a patient around resuscitation or ongoing care or intervention. Staff were aware of the patient’s background and alert to their needs as early as triage, or records being updated in more detailed discussions with the patient and their family. This meant staff had immediate information about a person’s resuscitation status and ensured that medical interventions aligned with patients’ wishes.

However, data received from the trust indicated shortfalls with ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) documentation. The ReSPECT Documentation Audit tracked performance from June 2025 to March 2026 and achieved an overall compliance of 65.7%. To address the audit failings, the ED Matron joined the Deteriorating Patient Working Group in late 2025 to launch an improvement plan. When records were available, staff provided medical interventions that matched the patient's preferences, ensuring dignified care. The ongoing collaboration between the Resus team and the ED Matron also led to new, practical changes such as identifying better locations to print and display ReSPECT information to ensure these documents remained visible despite high patient turnover.