Great Western Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that people and communities had the best possible outcomes because their needs were assessed. We checked that people's care, support and treatment reflected these needs and any protected equality characteristics, ensuring people were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

At our last assessment we rated this key question as good. At this assessment, we rated this key question as good. This meant people's outcomes were consistently good, and people's feedback confirmed this.

We have not awarded this service a score for Effective.

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

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Staff used relevant and recognised pre-assessment guidance and tools when assessing patients and their needs prior to surgery. These included a questionnaire called ‘MyPreOp’ which asked a series of questions to determine the patients previous and current health status.

Preoperative assessment clinic staff referred high risk patients to consultant-led clinics. For example, patients with high risk of complications due to frailty were assessed by consultant anaesthetists enabling pre-surgical optimisation for a safer patient outcome. This showed staff were competent to assess and respond to patient risk, and there were reliable systems to support this.

Staff throughout the service carried out risk assessments for patients in line with national guidance. Staff used the National Early Warning Score 2 system (NEWS2) to recognise patients who were becoming unwell. Patient observations were recorded on handheld devices, which calculated the NEWS2 score. The data was recorded on the patient’s electronic record and could be accessed centrally if required. However, an internal audit by the Acute Care Response Team (ACRT) had shown low compliance with staff recording NEWS2 scores effectively. The ACRT worked closely with ward based teams to improve their compliance with trust policy.

We reviewed a sample of patient records during the onsite inspection and found up to date assessments for vital signs, falls, nutrition, skin integrity, and Venous thromboembolism (VTE) risk. VTE is the risk of a patient developing a blood clot after surgery.

Staff throughout the service held huddles at regular intervals, each day and 7 days per week. Staff highlighted patient risk factors at these huddles, such as patients undergoing sepsis treatment and patients who required close monitoring, for example due to high blood pressure. Teams also identified patients who required safeguarding referrals.

Huddles were attended by all staff grades and disciplines. We saw leaders attended huddles to relay key safety messages. Staff clearly communicated key information. Staff used the SBAR (Situation, Background, Assessment and Recommendation) tool to communicate important information about a patient's condition to their colleagues. .

Staff told us they found the huddles very useful and enabled shared decision making when there were concerns about a patient’s observations or condition. Staffing levels were discussed in areas such as the wards and theatres.

The service had an inpatient ward audit schedule to ensure staff were using clinical tools in a suitable manner. Audits included reviews of infection prevention and control, falls, pressure damage prevention to protect people’s skin and medication management. The audit schedule was conducted via a series of monthly and 3 monthly audits.

Staff did not always follow current evidence-based good practice and standards. However, the service planned and delivered people’s care and treatment with them, including what was important and mattered to them.

Staff generally followed up-to-date policies to plan and deliver high quality care according to evidence-based practice and national guidance. These included guidelines from National Institute of Health and Care Excellence (NICE) and Royal College of Anaesthetists. Staff had access to guidelines on the trust’s intranet system.

There were printed versions of guidelines for emergency medicines in theatres. However, these were different to electronic versions on the trust website. We highlighted this to the service who immediately undertook a review of the guidelines available to staff and ensured the correct version was available for staff.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Clinical records we saw demonstrated care was provided in line with current guidance.

However, we observed nursing staff caring for 5 patients in the Post Anaesthetic Care Unit (PACU) who required enhanced airway management. These patients needed additional monitoring to ensure they were safely breathing. Staff monitored carbon dioxide levels for patients who were unconscious and not breathing independently during surgery. We saw this did not always continue when patients were transferred to and cared for in PACU. This meant there was a risk staff could take longer to recognise and treat a patient who was not breathing well. This practice was not in line with best practice guidelines published by the Association for Anaesthetists. Medical and nursing staff told us they were aware of these guidelines, but they were not always able to access the specialist monitoring equipment needed.

The service confirmed that whilst there was a risk to patients, there had been no evidence of harm or impact to patients as a result of this practice. We raised this with leaders who had started to review the service's practices with consultant anaesthetists.

There were systems to communicate changes in national guidance or changes to practice following an incident. These included team newsletters, SWIFT (Sharing Widely Improves Future Treatment) alerts and presentations to staff. On this inspection, we saw these processes were in use. Staff used information given regularly in safety briefings to implement new guidance or changes to existing procedures.

Practice educator nurses used noticeboards to communicate best practice guidance. For example, we saw noticeboards displaying best practice guidance for pressure damage prevention.

Audit data was collected in the service to assess their performance against national standards.

Patients awaiting discharge had access to hot and cold drinks and snacks. If a patient was staying on the ward overnight or longer they were offered hot meals. We discussed this with the management team, and they were aware but were balancing the confines of the hospital against the increasing needs of patients.

The service worked well across teams and services to support people. Staff worked effectively across different disciplines to ensure all staff involved in assessing patients' needs to maintain the continuity of care.

Staff effectively handed over people’s assessment of needs when patients moved between different services. This occurred within the hospital and during transfer or discharge. The hospital site team had a good understanding of the levels of care provided on each ward. This information enabled the site team manage safe staffing levels and understand the acuity level of patients.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. Relevant staff had access to electronic patient records which they could access using secure log-ins.

Staff who cared for patients on the ward had access to important records such as pre-assessment information. This supported staff in making informed decisions about the patient’s needs in the ward environment.

We observed effective safety huddles, team briefings, ward and board rounds where staff from multidisciplinary teams reviewed and discussed patients to ensure they received the correct treatment and care.

Staff provided peer and development support. For example, in Pre-Assessment each day a senior registered nurse was assigned the role of ‘nurse of the day’. The ‘nurse of the day’ role was not allocated a patient caseload. This meant colleagues in clinic could liaise with their colleague for guidance and support when pre-assessing patients.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff in pre-assessment were focused on patients and ensuring they were healthy enough to have the surgery they needed. Staff on wards encouraged post operative patients to get up, get dressed and sit out of bed where possible.

The service participated in initiatives to promote the health and wellbeing of patients attending for surgery. Patients were encouraged to be more involved in decisions regarding their care. For example, staff provided patients with information prior to attendance, published by the Royal College of Anaesthetists, to help them to prepare for surgery.

Smoking and alcohol usage were used as parameters for the clinical risk to patients and this was assessed at both the pre-assessment and admission stages of treatment.

The service routinely monitored people's care and treatment to continuously improve it. Staff ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Staff were supported by leaders to take steps to improve patient outcomes, through a variety of methods. This showed the service regularly reviewed the effectiveness of care and treatment through local and national audits. Leaders shared accurate and up-to-date information about effectiveness internally and externally and took steps to make sure staff understood it.

The service participated in mandatory national initiatives such as the Patient Reported Outcome Measures (PROMS) and the National Joint Registry (NJR). The service used outcomes data to assess their performance and improve. Both registers were designed to aid early review of specific patient groups for monitoring performance. National Joint Registry information/data recorded the type of implant, potential side effects and complications. The database enabled staff to contact patients in case the implant was recalled for safety reasons.

The service provided summary reports from September to October 2024, which showed the submission data to the PROMS data programme. Data from these schemes showed that the main surgical operations conducted at the hospital were hip and knee replacement surgery. PROMS data is mandatory for all hip and knee replacement surgeries under the NHS standard contract. PROMS for other types of surgery are not compulsory.

Outcomes for patients were monitored and action plans developed to improve the services. Staff told us that sometimes patients returned to hospital immediately after discharge. When this happened, staff reported this as a clinical incident and leaders investigated the reasons for the failed discharge.

Patient experience and outcomes were monitored as part of the PROMS process. Patient feedback under the category `success score' reported as `much better' was 86% for hip replacements and 75% for knee replacements. Similarly, `satisfaction' scores for `excellent' or `very good' were recorded as 45% and 32% for hip replacements and 29% and 35% for knee replacements. Based on this data the service was not an outlier compared nationally with other trusts.

The hospital monitored compliance with the sepsis bundle. In the last quarter of 2024 inpatient wards were 100% compliant with sepsis screening and giving antibiotics in line with National Institute for Health and Care Excellence (NICE) guidance.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff showed an understanding of consent processes and when to consider mental capacity in the consent process. We saw this was identified early during the pre-assessment phase of care.

Where consent for treatment could not be gained, staff understood their role in delivering care in the best interest of the patient. A checklist was completed on the electronic patient system which then produced alerts on the electronic patient record enabled staff to be aware of specific risks. For example, if a patient was assessed as having a high risk of fluctuating capacity or were living with dementia.

Staff had a person-centred approach and involved patients, where possible when completing risk assessments.

We observed staff obtained verbal consent from patients before interactions. Staff told us consent was gained during clinic appointment and again on the day of a procedure, and they provided examples of completed consent forms.

Staff referenced the trust consent policy which we reviewed as part of this inspection. Staff had access to mental health/deprivation of liberty safeguards guidelines on the trust intranet.

The trust had completed a consent audit in December 2024. The audit provided assurance all patients reviewed as part of the audit had been consented appropriately. However, the audit identified areas for development within current practice. For example, providing copies of consent forms to patients, providing information (leaflets) to patients during the consent process and some inconsistencies in completion of consent documentation (illegible hand-writing).