Great Western Hospital

Updated 8 March 2024

Pages 1 to 3 of this report relate to the hospital and the ratings of that location, from page 4 the ratings and information relate to maternity services based at Great Western Hospital.

We inspected the maternity service at Great Western Hospital as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

Great Western Hospital provides maternity services to the population of Wiltshire and surrounding areas.

Maternity services include a delivery suite with triage, a maternity theatre and a bereavement suite, midwife led birthing centre (White Horse Birth Centre), an antenatal and postnatal ward (Hazel Ward), a day assessment unit and antenatal clinics. Between April 2021 and March 2022, there were 3,740 babies born at Great Western Hospital.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out a short notice announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

Our rating of this hospital stayed the same. We rated it as Requires Improvement because:

• Our rating of Requires Improvement for maternity services did not change ratings for the hospital overall. We rated safe Requires Improvement and well-led as Requires improvement.

How we carried out the inspection

We provided the service with 2 working days’ notice of our inspection.

We visited Maternity assessment (Triage), Delivery Suite, the antenatal and postnatal ward (Hazel ward), White Horse Birth centre and the Day assessment centre.

We spoke with 2 matrons, 11 midwives, 4 specialist midwives 1 support worker, 2 student midwives, 2 women and birthing people, 1 birthing partner and or relative and 7 doctors. We received 2 responses to our give feedback on care posters which were in place following the inspection.

We reviewed 6 patient care records, 6 observation and escalation charts and 10 medicines records.

Following our onsite inspection, we spoke with senior leaders within the service; we also looked at a wide range of documents including standard operating procedures, guidelines, meeting minutes, risk assessments, recent reported incidents as well as audits and action plans. We then used this information to form our judgements.

You can find further information about how we carry out our inspections on our website:

: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

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.

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.

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.

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.

Updated 8 March 2024

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.

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.

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.