Great Western Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination.

At our last assessment we rated this key question as requires improvement. At this assessment we rated this key question as good. This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Managers and staff recorded accidents, incidents and complaints on an online electronic system. Staff said they used reflective accounts and practice to learn from incidents to minimise the risk of the same incidents being repeated.

Staff were encouraged to, and confident about, raising concerns. These were taken seriously, investigated and people received feedback. There were several ways in which people could raise concerns including, freedom to speak up guardian route, safety huddles and directly to their line manager or member of the senior team.

The trust had transitioned to the NHS England's Patient Safety Incident Response Framework (PSIRF). This meant the trust focused on effective learning and compassionate, meaningful engagement with those affected when incidents occurred.

However, some staff in theatres said they felt incident reviews and investigation processes were not always effective and some incident reviews were managed in isolation. For example, staff described not being fully included in the PSIRF process despite having been involved in incidents. We raised this concern with service leaders during the inspection who confirmed they would review their process going forward.

Data provided by the service showed where they had carried out thematic reviews in response to concerns and incidents. For example, the service carried out a detailed review of the hip surgery service following a national alert into increased mortality. As a result of the review the service made improvements which improved mortality rates. Additionally, the service undertook a thematic review following an increased number of never events in the surgical service relating to wrong site surgery. A never event is defined in the NHS as largely preventable incidents that should not occur if safety processes are followed. Following this review, specific actions were identified to improve processes and practise. For example, in response to wrong site surgery issues, we saw notices on display in wards about using the correct surgical skin marker to ensure surgical site markings made were not erased accidentally.

Trust data and evidence demonstrated how outcomes from incident investigations were shared using a variety of channels including via team briefs, safety huddles and by SWIFT (Sharing Widely Improves Future Treatment) alerts. This included learning from other areas of the trust when this was applicable. This ensured lessons learned were widely shared and minimised the risk of reoccurrence.

The service had established a Call 4 Concern service which was widely advertised so that staff, patients or their representatives could raise concerns about the care provided. This was used by the service as a tool for shared learning. For example, when a concern was raised, the specialist team prioritised investigating and addressing the immediate patient safety concerns. Once this was assured, the next steps were to address any other contributing factors in a supportive manner, enhancing care given to all patients. The service was able to demonstrate reduced instances of avoidable harm because of this initiative.

There was a central log of National Patient Safety Alerts, which leaders shared with staff and actioned as appropriate. We saw evidence that information had been shared with staff.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when people moved between different services.

The surgical service worked collaboratively with internal colleagues and external partners to maintain patients' safety. Continuity of care was maintained by effective handover of patients and their individual needs. Staff of all grades attended regular safety huddles during their shift. This was an opportunity to share safety information.

Alerts on the electronic patient record enabled staff to be aware of and follow specific care plans if a patient had needs that required additional support or there were signs of deterioration.

All planned surgical patients were pre-assessed prior to admission and surgery. There was effective sharing of pre-assessment information using embedded and agreed processes and systems.

There were good working relationships within the hospital to manage flow through the hospital. There were regular hospital level meetings and board rounds on wards throughout the day to ensure that patients waiting admission or discharge were facilitated in a timely manner. The site team had access to real-time data regarding the bed-state, for example the numbers of patients in beds, those awaiting further treatment or tests, and those awaiting discharge. This allowed the site team to identify potentially available beds and support ward staff in discharging patients.

Senior staff were aware of how many escalation beds they could safely accommodate. There were agreed processes in place with system partners should the hospital become full or near to full. For example, ambulances would be diverted to other hospitals. There were effective processes to manage non-surgical patients who were admitted to surgical wards from outside of the clinical speciality sometimes referred to as 'medical outliers'.

Effective systems supported daily reviews of patients by medical and nursing teams (Monday to Friday). Staff were aware of how to escalate concerns about patients whose condition deteriorated. However, patients told us the reasons for moving bays or wards were not always communicated effectively. They described how this often caused confusion for their relatives, as they did not always know which ward their loved ones were on.

Staff in the discharge lounge worked effectively to facilitate on-the-day discharges. This included liaising with the pharmacy department to ensure medicines to take home were ready. Working with ambulance liaison for transportation needs as well as communicating with families to ensure they were aware of the discharge of patients.

Risk assessments were completed for all patients and care plans reflected individual needs. The electronic patient record recorded these assessments for all care givers to see. We saw evidence of the review of risk assessments as the patient's condition changed.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff had access to in date safeguarding policies and guidance through hospital electronic systems. Staff received training specific for their role on how to recognise and report abuse. Records showed safeguarding training was in line with national guidance for clinical staff caring for adults and children.

Staff, from all areas within the surgical service, we spoke with during the inspection could identify what constituted abuse and how to report their concerns to the safeguarding team. The hospital safeguarding team were available during office hours. Staff told us they were very supportive and responsive when contacted.

Staff could give examples of how to protect patients from harassment and discrimination including those with protected characteristics under the Equality Act. Staff understood the importance of supporting equality and diversity and ensured care and treatment was provided in accordance with the act.

There was no evidence of a closed culture and staff told us managers were approachable.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people's needs that was safe, supportive and enabled people to do the things that mattered to them.

The surgical service worked with people to understand and manage risk by thinking holistically. Staff put patients at the centre of their own care. Staff spent time with patients to understand their individual needs. For example, ward based staff used board rounds to discuss individual patient needs and circumstances, both physical and social.

All patients attending for planned surgery were pre-assessed. Staff trained in pre-assessment completed pre-assessments with patients either remotely, over the telephone or in a face-to-face clinic. Staff demonstrated how information was entered into a computer system which guided them through the required parameters.

Leaders and staff could articulate what risk assessments they used to keep patients safe. The electronic patient record flagged when patients were at risk of deteriorating and the outreach team actively sought out those patients whose risks were increasing. Staff used observational tools and measurements of vital signs, such as temperature or blood pressure, to recognise signs that a person may be deteriorating. These were recorded on the trust electronic record keeping system which could be accessed by different teams, including nursing, medical and site teams.

The Acute Care Response Team (ACRT) conducted audits of the patient management system. This provided a safety net for patients at risk of deterioration.

The ACRT also reviewed compliance against the completion of National Early Warning Score 2 (NEWS2) recording when an inpatient was admitted or moved to a ward area. The data was used to support ward based colleagues to improve their practice. Staff could describe the support they had received from the ACRT.

For example, the ACRT audit of NEWS2 completion determined that in November 2024 the trust was achieving 53% compliance against a target of 95%. During February 2025 the trust had improved its position to 62% compliance. However, despite the low compliance with recording scores on admission, staff checked patients effectively in ward environments and took action as required in line with trust policy.

Staff knew how to escalate and monitor patients identified as deteriorating or that they were concerned about. Patients and relatives could utilise the Call 4 Concern process. Call 4 Concern was well embedded in the culture of the staff and was clearly displayed to patients and their families. Concerns raised with this team were treated seriously and investigated to manage any risks.

The service used the trust electronic patient record system which enabled staff to be aware of specific risks for patients. For example, if patients were at the end of their lives, living with dementia or at risks of falls. Staff had a person-centred approach and involved patients, where possible when completing risk assessments. Patients we spoke to said that they had been involved in planning their care.

Staff shared information when handing care over to other teams using SBAR (situation, background, assessment and risk), a structured communication tool. This ensured handovers contained all relevant information regarding a patient. Staff described this as a more efficient and safer handover of care. Each episode of care was recorded by health professionals on the electronic patient notes system and any paper records being used.

Staff told us procedures were in place to support patients with mental health conditions. There was guidance for the use of rapid tranquilisation and restraint, to ensure staff understood the legal framework for the use of them. Trust policy was that only security staff and police who had completed required training could carry out physical restraint. In accordance with trust policy, nursing staff had no training in restraint but did receive training in conflict management.

Staff changes and handovers included all key information to keep patients safe. During the inspection we attended handovers and safety huddles and found all the key information needed to keep patients safe was shared. Each staff member had an up-to-date handover sheet with key information recorded.

The service did not always detect and control potential risks in the care environment. Staff did not always make sure equipment, facilities and technology supported the delivery of safe care.

The demand on the hospital and the surgical service had outstripped capacity, and the hospital was using all available space for patient care.

Staff told us the Daisy Ward / Day Surgery Unit (DSU) was often used as an escalation ward overnight. When this happened, staff patient dignity and privacy was respected by complying with national guidance on same-sex accommodation. Patients had access to a toilet, hand basin and shower facilities in the ward. The ward did not have any natural light, and both staff and patients reported the temperature was often high. As a result, the hospital had installed portable air conditioning units and air filtration units. However, these units were noisy and both staff and patients reported the noise to be a concern. Patients told us they had difficulty getting sleep due to the noise.

Staff in the Daisy Ward / DSU told us their morale was negatively affected by the environment and the continual use of the day surgery unit as an escalation area.

Meldon ward, a ward for surgical patients had escalation beds located in 3 bedded bays. This increased the number of beds in those bays from 4 to 5. Additionally, a further 2 temporary spaces had been identified in different bays. All these additional spaces could have both surgical or medical patients and were to be used in exceptional circumstances and for a limited time only.

However, the space around the escalation beds was limited and did not easily allow for any additional equipment, such as emergency equipment. There was limited space to accommodate visitors. There was also no piped oxygen or suction available for these spaces. Due to the restricted space, infectious patients were risk assessed and not placed in these spaces due to the close proximity of other patients. The service mitigated these risks with the use of portable oxygen and emergency equipment. Curtains had been installed to allow for privacy and dignity of patients.

Staff in both the operating theatres and wards had access to equipment and consumables they needed. However, there was limited space for the storage of equipment and consumables. Some wards appeared cluttered when patients needed a lot of equipment alongside their personal belongings around the bedspace.

In theatres we found inconsistent use and design of white boards, used to record all items used during surgery such as the equipment count. These are known as `count boards' and best practice suggests a consistent layout of these boards, together with a standardised approach, promotes safer working. Count boards throughout the theatre suite had different layouts, which could lead to an inconsistent approach to counting equipment and disposable items. This increased the risk that items were not recorded in a consistent way, in turn increasing the risk that items were not identified and counted as defined within trust policy, national standards and best practice guidelines. For example, leading to possible retained item post-operatively, an item left inside the body, if a count failed.

Anaesthetic Practitioners were required to complete daily anaesthetic machine safety and cleaning checks. Trust guidelines indicated these checks were to be recorded centrally within the theatre suite. The guidelines outlined specific activities to be carried out by the Anaesthetic Practitioner for each allocated theatre. These included safety checks for: anaesthetic machines, oxygen cylinders, other equipment and also included cleaning of all surfaces and restocking of consumables. We reviewed records for February and March 2025 showing staff had signed to confirm they had fulfilled the requirements of their role and duties.

The equipment we saw was visibly clean. Planned preventive maintenance and electrical appliance tests were completed annually and recorded centrally. We checked equipment and it had undergone electrical safety checks within the last 12 months. The department's fire safety equipment and emergency systems such as call bells, were tested and maintained appropriately.

There were effective systems to ensure emergency equipment in medical wards was checked daily. Medical gases were stored securely. Cleaning products were kept in a locked cupboard and Control of Substances Hazardous to Health (COSHH) data sheets were available.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care that met people's individual needs.

Staffing was planned and managed according to national guidance. Leaders used recognised staffing tools to ensure there were enough staff to deliver care and treatment.

The trust had effective recruitment processes and ongoing checks to ensure all staff met the legal requirements to work in the trust. The service was aware of the challenges they faced in recruitment and the areas which required further support.

The service supported staff induction and continued professional development. Training days were organised multiple times a year in focused relevant areas. Staff told us they were provided cover to attend the training. A mentorship programme was available for staff to continuously identify and develop skills.

Staffing was discussed during regular site management meetings at trust level so staff could be deployed if needed. Staffing was monitored through governance meetings and by the Director of Nursing to ensure there were sufficient staff to provide care. Where necessary, temporary staff were utilised, primarily bank staff who were employed by the hospital. Temporary staff usage (including bank and agency) was less than 5% for nursing staff (January 2025 to March 2025). The low rate of temporary staff use indicated effective management of staffing levels.

Staff followed a programme of mandatory training. Staff told us the training provided was effective and they felt supported to access more training if they needed it. Mandatory training subjects included, but were not limited to, safeguarding, infection control, health and safety, moving and handling, information governance and equality and diversity. Training was a mix of e-learning and face to face sessions. Nurses were trained in medicine management, and their competencies were checked annually. Nurse leaders had access to dashboards displaying compliance rates for staff they managed. We reviewed a sample of dashboards during the inspection which showed staff had completed the required training.

Nursing staff on wards had training in managing a deteriorating patient, specifically ILS (Immediate Life Support). In other areas, such as pre-assessment, nursing staff had training in specific key competencies to allow them to carry out their role safely and effectively.

In theatres, resident doctors reported a positive learning environment and enjoyed working there. However, some anaesthetists reported not always being fully supported to develop their own careers. For example, one member of staff described not feeling valued or supported to complete the Certificate of Eligibility for Specialist Registration in the UK (CESR). This is route to entry onto the Specialist Register for doctors who have not completed a GMC-approved training program. This is an alternative to the standard Certificate of Completion of Training (CCT). CESR allows doctors, particularly those with overseas training or non-standard training, to demonstrate their equivalent knowledge, skills, and experience to become eligible for consultant posts in the NHS.

Managers confirmed the turnover rate for surgical services was 9.58%, which was below (better than) the trust target of 11%. This indicated the service was performing well in maintaining a stable workforce.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of infection, preventing spreading and sharing concerns with proper agencies promptly.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff followed infection prevention and control (IPC) guidance, washed hands between patient contact and wore appropriate Personal Protective Equipment (PPE).

The trust had an infection control policy in place that staff had access to electronically. There was an infection control lead and infection control link nurses available to support the staff with any infection concerns.

Operating theatres and wards looked visibly clean. Cleaning staff were visible in most wards and departments. Surgical wards appeared clean and free from dust including in hard-to-reach places. We observed nursing staff cleaning their clinical areas and equipment during periods of downtime or before clinics had started, for example in pre-assessment.

The trust monitored the number and type of infections seen in the hospital. Regular audits were mostly carried out by teams in clinical areas, supported by the infection prevention and control team. Hand hygiene and environmental audits including equipment audits were carried out. The results of these audits were discussed with the relevant departments and an action plan to identify areas of deficit agreed. Random sampling of hand hygiene audits in the surgical service carried out in February 2025 demonstrated the wards were consistently over 95% compliant.

Staff had access personal protective equipment (PPE) stations around the service The stations included hand sanitiser, gloves in all sizes and aprons for staff. Staff used PPE correctly. Clinical waste was managed safely and segregated appropriately.

Staff were trained in the management of surgical wounds. Staff understood the risks and the impact of surgical site infections (SSI) for patients.

The surgical service had reviewed their own data and identified their surveillance and oversight of SSIs was not robust enough. The service had developed and put into effect a series of actions to improve their position, and this included a business case for additional staff to support and coordinate the SSI prevention work.

Patients who required isolation care were provided with single rooms and staff managed barrier nursing effectively. These practices protected staff and patients from the spread of infection.

The service made sure that medicines and treatments were safe and met people's needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicine trolleys were locked and securely fixed to the wall when not in use. The trolleys were well organised and easy to navigate, with different sections, for example, for antibiotics and analgesia. Medicines were administered by registered nurses and appropriately recorded in patients' records.

If patients wanted or preferred to self-medicate, this was supported by staff following the completion of a risk assessment. This ensured patients had the mental capacity to make the decision, ability to safely undertake this task and understood the need for safe storage. Patients were not allowed to keep their own controlled drugs.

Stock medicines were stored in locked cupboards in the clinical room on each ward or department. Clinical rooms were locked and could only be accessed by authorised staff. Room and medicine refrigerator temperatures were recorded daily.

Staff told us, and we saw, pharmacists and pharmacy technicians reviewed drug charts and carrying out medicine reconciliations on surgical wards. Medicine reconciliations are carried out to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions.

We reviewed drug chart audit data and saw staff did not always document height and weight of their patients. This meant patients could be prescribed and administered the incorrect dose of medicines that are calculated by height and/or weight. This was raised with the trust during feedback and reminders were issued to staff during the inspection. In all records looked at the Venous Thromboembolism (VTE) risk assessments had been completed.

Controlled drugs (CDs) were stored in cupboards compliant with national requirements relating to the misuse of drugs regulations and the associated health building note. CDs were counted twice a day by 2 registered healthcare professionals and the register signed to confirm they were all present and correct. Controlled Drugs were checked and found to have matched documentation.

Patients admitted with their own CDs had these stored in a separate CD cupboard, which also met minimum standards required for safe storage. These medicines had a separate CD register and were also checked twice a day by two registered healthcare professionals.

Pharmacy staff audited controlled drugs records to ensure compliance with trust policy. This included stock levels, administration and disposal doses. We saw records provided by the trust to support this the audits had been carried out effectively.

Staff were trialling a process of administering specific fluids administered intravenously (IV) by one member of staff. The trial had oversight and support from the trust medicine safety team to ensure patient safety was maintained Previously there had been a requirement for 2 members of staff to sign out these specific IV fluids. Leaders and staff described how this had led to a significant saving in time for staff and a positive impact on the timeliness of patients receiving the fluids.