You are here

Great Western Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 30 June 2020

Our rating of services stayed the same. We rated it them as requires improvement because:

  • We rated safe and responsive as requires improvement. Three of the hospital’s eight core services (including critical care, which was not inspected this time) were rated requires improvement in safe and three of the hospital’s eight core services were rated requires improvement in responsive.
  • We rated urgent and emergency care and surgery as requires improvement overall. Although we saw the trust had made much improvement in some areas since our last inspection in 2018, there was still further improvement required and the ratings remained the same. However, the ratings for medical care and maternity services had improved. We rated medical care as good overall, with safe, effective, caring and well-led rated good. This was a significant improvement since our last inspection. We rated maternity services good overall, with all key questions rated good.
  • We were not assured that risks to patients were always promptly assessed and mitigated. Systems to ensure patients attending hospital in an emergency were assessed quickly and prioritised, were not always effective. Patients brought to the emergency department by ambulance were not always promptly handed over to, or assessed by, emergency department staff. The trust did not meet national standards in this regard. In surgery, although we saw theatre safety checklists were completed, the trust’s audit processes did not provide effective assurance. The trust acted on this concern swiftly following our inspection.
  • The design, maintenance and use of premises and equipment did not always keep people safe. The emergency department was not designed to accommodate the significantly increased number of attendances and was frequently crowded, as were inpatient assessment areas. It was difficult for staff to work in congested areas, where the movement of staff, patients and equipment was compromised and posed a risk. Equipment checks were not carried out consistently in all areas.
  • The service did not always control infection risk well. In surgery we had concerns about cleanliness in theatres and the effectiveness of systems to control the risk of infection. In the medical expected unit, we found soiled equipment and fittings in bathrooms. In the emergency department and the surgical assessment unit, crowding impacted on the service’s ability to isolate infectious patients.
  • Although records management had improved overall, in maternity, records were not always clear or easily accessible to staff providing care. In the emergency department, nursing documentation was not always completed to demonstrate that patients received regular assessment.
  • The service did not always have enough staff with the right qualifications, skills, training and experience to provide the right care and treatment. There were not enough children’s nurses employed in the emergency department and the service did not employ a consultant in paediatric emergency medicine, as recommended by national guidance. The service was taking steps to mitigate this staffing shortfall and associated risks. In surgery, staff shortages were reported in a number of areas. Nursing staff on some surgical wards, which accommodated medical patients, felt staffing levels and skill mix did not match the needs of this patient group and contributed towards failings in care. Although the majority of patients we spoke with were positive about staff, there was an acknowledgment that sometimes they were not as responsive as they would have liked because they were so busy. Allied health professionals in surgery mostly worked only Monday to Friday, although a weekend service was available for patients who needed mobilisation to get home.
  • Not all staff were up to date with mandatory training in safety systems and processes. Compliance with trust targets for mandatory training had improved in most areas, although some further improvement was still needed, particularly for medical staff in the emergency department.
  • We were not assured that staff always had access to up-to-date policies and protocols. In maternity and urgent and emergency care we found policies and protocols which were overdue for review.
  • The trust’s readmission rates for some surgical specialities were worse than the England average, which may be an indicator of sub-optimal care.
  • Patients did not always receive care at the right time and in the right setting. The service did not meet national standards in respect of waiting times in the emergency department. Patients in the emergency department waited too long for their treatment to begin and for an inpatient bed to become available, once a decision had been to admit them. Five surgical specialties were below (worse than) the England average for referral to treatment times for patients admitted to hospital. The percentage of patients whose surgery was cancelled and were not treated within 28 days was worse than the England average.
  • Demand and capacity were the hospital’s biggest challenges and facilities and premises were not always suitable for the purposes for which they were used. Patients were often cared for on trolleys in the corridor in the emergency department and in inpatient assessment areas. This was not a comfortable or dignified experience. Inpatients were not always cared for in the most appropriate ward or in areas, which were designed for inpatient care and had suitable facilities. Some inpatients were moved frequently during their inpatient stay, sometimes at night, and accommodated in areas where single sex accommodation could not be provided. Some patients, particularly those who had waited overnight on trolleys or on chairs, expressed to us feelings of frustration, tiredness and told us how uncomfortable they were. On one ward patients complained that payphones and televisions were not working and use of wet rooms resulted in water seeping into ward bays. The trust took action to address this when we raised this with them.
  • Governance arrangements in the planned care division were in development. Divisional performance meetings were not recorded so there were not adequate or informative records of discussion and decision making.

However:

  • Staff understood how to protect patients from abuse. The service mostly managed medicines well and kept good care records. This had improved since our last inspection. The service managed patient safety incidents well.
  • The service was taking sensible and creative steps to address staffing shortages. In the planned care division, a skill mix review had resulted in additional staff employed in areas identified as being at risk. In medical care, additional staff had been funded in the emergency department and acute medicine to reflect increased demand on the service. The trust was developing new roles to improve staffing and resilience
  • Staff provided good care and treatment, gave patients enough to eat and drink and gave them pain relief when they needed it. Managers monitored the effectiveness of care and treatment. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Most key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers. We heard examples where staff had ‘gone the extra mile’, for example staff had taken patients’ washing home and given patients gifts at Christmas.
  • The trust recognised demand and capacity were their biggest challenges and they were focused on making the most efficient use of the resources at their disposal to deal with the daily operational pressures these challenges presented. The site management team and operational and clinical managers had good oversight of patient activity, demand and flow. The risks associated with crowding were understood and leaders worked relentlessly to ‘share the load’ and to manage risks as far as possible. A full hospital protocol had been developed to inform decision making. The trust had developed a new ‘stranded patients’ initiative, which entailed a daily review, led by the trust’s medical director, of all patients with a length of stay of seven days or more.
  • The service was inclusive and took account of patients’ individual needs and preferences. The service had 24-hour access to mental health liaison and specialist mental health support if staff were concerned about a patient’s mental health. There was also a learning disabilities team. Staff used ‘this is me’ documentation and hospital passports to capture information about patients in vulnerable patient groups, such as patients living with dementia and patients with a learning disability. We heard examples where staff had taken extra steps to support anxious patients.
  • It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with staff.
  • Leaders ran services well, using reliable information systems and supported staff to develop their skills. Leaders were visible and approachable, and staff felt well supported and valued by them. Staff were focused on the needs of patients receiving care and this remained their focus in spite of relentless operational pressures. Staff understood the service’s vision and values, and how to apply them in their work. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

Inspection areas

Safe

Requires improvement

Updated 30 June 2020

Effective

Good

Updated 30 June 2020

Caring

Good

Updated 30 June 2020

Responsive

Requires improvement

Updated 30 June 2020

Well-led

Good

Updated 30 June 2020

Checks on specific services

Medical care (including older people’s care)

Good

Updated 30 June 2020

Our rating of this service improved. We rated it as good because:

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
  • Leaders ran services well, using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

  • At times of high demand, patients were not always cared for in the right setting and many patients experienced multiple moves within the hospital.

Services for children & young people

Good

Updated 21 December 2018

Our rating of this service improved. We rated it as good because:

  • Patient safety was a priority for this service. Staff numbers had been low but were improving and managers had a strategy to recruit and retain staff to the children’s service to create stability. Where there were gaps in rotas, these were filled with bank and agency staff.
  • Managers used trust governance processes to assess quality of care delivered and passed information to staff on areas needing improvement.
  • Staff followed infection control processes and monitoring showed infection rates were low.
  • Staff working in children’s specialty areas were trained to care for children. Support was provided for children and families when they left the hospital and outreach staff communicated well with community and children’s services colleagues.
  • Safeguarding processes were followed by staff and staff were knowledgeable about how to identify and manage potential abuse for children. Support was offered to staff with supervision and training.
  • There were enough medical staff to care for children in the hospital.
  • There was a noticeable change in culture, compared with our previous inspection. Staff felt supported, able to contribute ideas and voice concerns if they needed.
  • Leaders and managers were aware of the challenges to the service and that quality needed to be improved. They were using trust structures to monitor progress and using their own ideas to contribute to improvement.

However

  • Mandatory training modules did not always meet trust targets for staff attendance. This included medical staff in the children’s unit and some staff who cared for children in other parts of the hospital such as radiology, outpatients departments and surgical areas. There was, however a plan to improve this compliance.
  • A limited oversight of shift patterns meant that bank and agency staff could work long hours and shifts which did not give them enough rest.
  • Oxygen administration for children who needed it was not consistently prescribed.
  • GPs did not always receive discharge summaries about a child’s care in a timely way.
  • There was no non-executive lead to champion children’s services at the trust board.

Critical care

Good

Updated 4 August 2017

​We rated this service as good because:

  • There was a good incident reporting culture, learning was identified and staff received feedback from incidents.
  • There were safe nursing and medical staffing levels to deliver effective care and treatment.
  • The service provided care and treatment in line with evidence-based guidance.
  • There were experienced nursing and medical staff who received annual appraisals and were supported with training and professional development.
  • The service monitored patient outcomes and these were good when compared nationally and to other similar units.
  • Staff cared for patients with compassion and kindness. Staff treated patients with respect and dignity at all times.
  • The provision of the service met the needs of most people.
  • Patients’ individual needs were met wherever possible.
  • There were clear governance and risk management processes.
  • There was strong leadership and teamwork.

However:

  • Provision for therapy services did not meet national guidelines. There was not sufficient physiotherapy and dietitian support, and limited support from other therapies.
  • There was a slightly higher than national average of delayed discharges for patients. However, this did not result in any significant delays in admitting new patients.
  • There was only one junior doctor in the unit at night, when standards recommended a unit of this size should be covered by two at all times.
  • Junior medical staff were not all ‘airway competent’ with skills in advanced airway techniques.
  • Patients were occasionally transferred to general wards at night, which was not optimal for their care.

End of life care

Good

Updated 19 January 2016

We judged the overall service provision of end of life care as good. We found the service to be safe, effective, caring, responsive and well-led.

End of life care was seen as a priority for the trust. There was a clear overarching strategy for the service and plans to improve the delivery of care had already begun to take place with good results Education programmes had been developed and delivered, new documentation had been successfully introduced to the trust improving the pathway for patients although there was also some , yet to be fully embedded.

Staff, patients and relatives spoke in high regard for the specialist palliative care team; they were seen as responsive to the needs of both patients and staff. Out of hours there were good resources for staff to access including a 24 hour advice line managed by specialist palliative care nurses at a local hospice.

End of life care was responsive to the needs of patients and relatives. The end of life service was flexible and provided choice and accommodated individual needs for the patient and carers.

The specialist palliative care team had been involved in looking at complaints and incidents, as part of a wider team, and were keen to ensure training and teaching sessions were tailored and disseminated to ensure future complaints were minimised and care of patients was enhanced.

The specialist palliative care team were dedicated members of a cohesive team working to deliver effective care and treatment plans for patients, offering advice and acting as a resource for clinical teams.

Surgery

Requires improvement

Updated 30 June 2020

Our rating of this service stayed the same. We rated it as requires improvement because:

We rated safe and responsive as requires improvement. We rated effective, caring and well-led as good.

  • Some areas were not fully staffed, although the trust was taking steps to address shortages.
  • The service did not always control infection risk well. The design, maintenance and use of facilities, premises and equipment did not always keep people safe.
  • The audit process for completion of the World health Organisation's surgical safety checklist did not provide effective assurance.
  • Not all key services were available seven days a week.
  • People could not always access the service when they needed it or receive the right care promptly and in the right setting.
  • Leaders did not always operate governance processes in accordance with trust policy.

However,

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff kept good care records, managed patient safety incidents well and learned lessons from them.
  • Staff provided good care and treatment, gave patients enough to eat and drink and gave them pain relief when they needed it. Managers monitored the effectiveness of the service. Staff worked well together for the benefit patients, advised them on how to lead healthier lives, and supported them to make decisions about their care and treatment.
  • Staff mostly treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. They provided emotional support to patients, families and carers.
  • The service mostly took account patients’ individual needs made it easy for people to give feedback.
  • Leaders ran services well, using reliable information systems and supported staff to develop their skills. They understood and sought to manage the priorities and issues the service faced. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service engaged with patients and the community to plan and manage services and all staff were committed to improving services continually.

Urgent and emergency services

Requires improvement

Updated 30 June 2020

  • There were not always enough appropriately trained and skilled staff to care for children. Staff had training in key skills but not everyone had completed it. The emergency department was not big enough to meet increased number of patients and was frequently crowded. The service did not always control infection risk well. Staff assessed risks to patients, but they did not always do this swiftly on their arrival in the emergency department. Ambulance handover and initial assessment were sometimes delayed. Records were not always managed well.
  • Managers did not always ensure that staff were competent. Staff were not required to complete competency-based training and assessment.
  • Patients sometimes waited too long for treatment. The service was not meeting national targets in respect of waiting times.
  • We were not assured there was enough oversight of risks to the services delivered.

However:

  • Staff understood how to protect people from abuse and mostly managed medicines well. The service managed safety incidents well and learned lessons from them.

  • Staff followed evidence-based clinical pathways and monitored the effectiveness of care and treatment they delivered. Staff worked well together for the benefit of patients and had regard for people living with mental health conditions.

  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs and helped them understand their individual conditions. They provided emotional support to patients, families and carers.

  • The service planned and provided care to meet the needs of local people, took account of patients’ individual needs as far as possible and made it easy to provide feedback.

  • Leaders ran services well and supported staff to develop their skills. The service had a vision and strategy to improve service delivery to meet increasing demands. Staff felt respected, valued and supported. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and staff were committed to improving services continually. There were effective governance structures to ensure quality of care.

Maternity

Good

Updated 30 June 2020

We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings.

We rated it as good because:

The service mostly had enough staff to care for patients and keep them safe. The midwife to birth ratio had improved since our last inspection. Staff understood how to protect patients from abuse and managed safety well. Staff assessed risks to patients and mostly acted on them promptly. The service controlled infection risk well and mostly managed medicines well. The service managed patient safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.

  • Staff provided good care and treatment, gave women enough to eat and drink and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent for their roles. Staff worked well together as a team to benefit women, advised them on how to live healthier lives, and supported them to make decisions about their care. Key services were available seven days a week.
  • Staff treated women with compassion and kindness, respected their privacy and dignity, took account of their individual needs and helped them understand their conditions. They provided emotional support to women and families.
  • The service planned and provided care in a way that met the needs of local women, took account of women’s individual needs and made it easy for people to give feedback. Women could access the service when they needed it and usually received the right care promptly.
  • Leaders ran services well, using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

  • The service provided mandatory training in key skills to all staff but not everyone completed it. Staff kept detailed records of women's care and treatment, but records were not always clear, up-to-date, stored securely and not always easily available to all staff providing care.

Outpatients

Good

Updated 21 December 2018

  • We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings.
  • We rated it as good because:
  • Staff understood how to protect patients from abuse; there were clear processes for reporting safeguarding concerns and staff knew how to access support to do this.
  • There were systems and processes in place to protect patients and visitors from the risk of infection.
  • There were systems in place for managing the planned maintenance of equipment and when faults were identified.
  • Staff could identify and respond to a deteriorating patient within the outpatient environment, including medical emergencies.
  • Patient records were accessible and staff had the information they needed to make informed assessments of care needs.
  • Medicines and prescription pads were appropriately managed to keep people safe in line with national guidance and legal requirements.
  • Staff understood their responsibilities to report near misses, patient safety concerns and incidents.
  • The physical, mental, and social needs of patients were holistically assessed. The care and treatment provided was underpinned by the relevant standards, legislation and evidence-based guidance.
  • Nutrition and hydration was considered as part of the patient assessment. Refreshments were also available to patients in the outpatient setting.
  • There was an established audit programme to monitor the outcomes of patients’ care and treatment within the outpatient setting.
  • Staff had the qualifications, knowledge and skills to be able to assess and meet the care needs of patients. Staff were encouraged to develop through accredited learning and training programmes developed by the organisation.
  • Professions worked together to provide seamless patient care, including when care was provided across different specialisms.
  • Patients were treated with compassion, kindness, dignity and respect throughout their visits to outpatient services.
  • Clinical consultations and conversations regarding people’s health and well-being needs were conducted within clinical areas with the door or curtain closed to maintain confidentiality.
  • Patients with mental health needs were treated with compassion and without judgement.
  • Staff provided emotional support to patients to minimise their distress including when a life-changing diagnosis was given.
  • Patients were signposted to sources of further information, including other providers and community services that could support their care.
  • When patients were finding decisions difficult, staff supported them to understand the complex information about their condition.
  • Those close to the patient were made to feel part of the conversations and able to contribute to discussions regarding health needs and care plans.
  • The services provided reflected the needs of the local population by offering choice, flexibility and continuity of care.
  • The trust was performing better than the operational standard for people being seen within two weeks of an urgent GP referral, to receive treatment within 31 days of diagnosis and the standard for patients to receive their first treatment within 62 days of GP referral.
  • The trust had instigated an outpatient transformation programme, which aimed to improve the services delivered to the local population. This included offering additional clinics and establishing more efficient ways of working.
  • The trust identified where a system-wide approach was needed to meet the needs of the local population. Within endocrinology, rheumatology and dermatology, work was ongoing with commissioners and partners in primary care to find solutions to the demand for services.
  • Staff supported patients with additional needs such as patients living with dementia. An alert was placed on patients’ records and early appointment times allocated to reduce anxiety.
  • Translation services were available for patients whose first language was not English.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.
  • There was a clear strategy for outpatient services to deliver a transformation programme. Staff were highly engaged with this and understood their role in delivering the vision.
  • There was generally a positive culture within outpatient services, except for one area reporting low morale. Many staff, of all grades, told us they felt part of a team and described a supportive and respectful working environment.
  • The board and other levels of governance in the organisation functioned effectively. There were clear lines of accountability and information was shared effectively.
  • Senior nurses had joined together to create an outpatient nursing forum with representation from specialities across the organisation. The purpose of the group was to establish more uniform ways of working across divisions to improve quality and efficiency.
  • From speciality to board level, risks and issues were recorded, reviewed, escalated and managed to reduce the likelihood of patient harm.
  • Information was used as part of decision-making and to monitor performance. A divisional dashboard had been developed to provide an overview of service provision and monitor potential issues.
  • Senior staff had taken steps to improve staff engagement. An outpatient forum had been set up for staff nurses to attend.
  • There was a focus on learning, improvement and innovation throughout outpatient services, driven by the outpatient transformation project.
  • However:
  • Not all nursing and medical staff were up to date with their required mandatory training, including safeguarding.
  • Lack of space was identified as an issue in several areas we visited, including the Coate Water Unit, oncology/ haematology clinics, endoscopy, cardiology, and the breast clinic.
  • We found unattended patient records in an unlocked room in the orthopaedic clinic and Wren Unit.
  • We did not observe the use of ‘I am clean’ stickers or a similar system to notify staff that equipment was cleaned and ready for use.
  • We were not assured that all staff could identify if equipment was fit for clinical use. Servicing labels did not contain the next service date and the responsibility for maintenance of specialist equipment was not clearly understood by staff.
  • Seven-day services were not routinely offered to outpatients due to a lack of resources to extend services beyond the working week.
  • We raised concerns that privacy was not maintained within the blood test clinic, where doors were left open and curtains were not used to hide patients from the view of others.
  • Waiting times meant people did not always have timely access to an initial assessment or treatment. The trust had developed processes for managing the risk and prioritising patients.
  • Despite improvements made through a space utilisation programme, the premises were not sufficient to deliver the number of appointments required to meet demand.
  • Complaints were not always investigated within national time frames. At the time of our inspection 17 investigations regarding complaints were overdue.
  • We raised concerns a long-term sustainable plan for outpatient services had not yet been developed. The trust was evaluating the ability of demand predication tools to capture both new and follow-up appointments.
  • Governance meetings were not consistently organised to follow a set template, the detail of discussion was not always captured in the minutes to allow retrospective comparison.
  • Patient feedback was not consistently engaged or reviewed to measure level so satisfaction.
Other CQC inspections of services

Community & mental health inspection reports for Great Western Hospital can be found at Great Western Hospitals NHS Foundation Trust.