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 good. At this assessment the rating has remained the same.

This service scored 67 (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 made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Staff effectively communicated with patients to meet their needs. For example, we observed a member of staff communicating patiently, kindly and compassionately with a patient who had a hearing impairment.
Staff discussed people’s needs with them, and they were involved in how care and treatment was planned. Patients were offered pain relief and refreshments while they waited to be seen by a clinician.

Staff assessed and acted on risks to patients of avoidable harm. Staff worked with other specially trained professionals to support people with additional needs. We reviewed an incident report which related to a patient who had presented with mental health needs. The patient was referred to the mental health liaison team who reviewed him and signposted to support in the community.

Staff had access to a framework for supporting patients with physical disability. The framework provided staff with information on understanding the needs and preferences of patients and caregivers and how best to support them. We observed a patient who was hard of hearing who attended the department with their carer. Staff ensured they were provided with all the information and signposted them to the relevant area of the department.

The trust had recently established a streaming role for adults attending the unit. The objective of the streaming practitioner (SP) was to identify those patients who required a rapid assessment to be able to ascertain if they needed early discharge or early referral to specialist services to meet their individual needs.

Records we saw were up to date and showed detailed assessments were undertaken leading to effective ongoing care meeting people’s needs.

Staff could add flags to patient records to identify patients with additional needs or who might require additional support. This included alert flags for patients with allergies, mental health needs, learning disability needs, autism or dementia needs. They could also record Recommended Summary Plan for Emergency Care and Treatment (RESPECT) forms, which created a personalised recommendation for clinical care in emergency situations, where patients were not able to make decisions or express their wishes. We saw evidence of this on patient records during the inspection.

The department focused on supporting patients classed as high intensity users through the development of care plans, collaboration with a wide range of partners and services, and direct liaison with patients to understand their needs and adapt care to support them appropriately. Through this service, patients were supported to have their underlying needs identified and met and received informed care when attending ED.

The service planned and delivered people's care and treatment with them, including what was important and mattered to them. Staff did this in line with legislation and current evidence-based good practice and standards.

Staff followed up-to-date policies to plan and deliver quality care according to evidence-based practice and national guidance. We reviewed a sample of the service's policies and guidelines and noted that all were in date with a set review date. Staff supported patients to understand their treatment and had good knowledge of the communication resources, and options available to them.

We reviewed patient records and found these to be detailed with important information which linked with current good practice on how to support people with their health conditions. These included interventions staff had made, and advice sought when required.

The department undertook audits and analysed the trends and shared this with all staff. The service used the National Institute for Health and Care Excellence (NICE) guidelines to ensure that care was evidence based and participated in all relevant Royal College for Emergency Medicine (RCEM) audits.

Staff protected the rights of patients subject to the Mental Health Act 1983. At handover meetings, staff routinely referred to the psychological and emotional needs of patients, their relatives, and carers.

The service worked well across teams and services to support people. Staff made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

There were good working relationships between staff in the department and the team worked well together given the high demands and pressures in the department. We saw a flat hierarchy where staff at all levels were able to speak up and challenge colleagues in a supportive way.

Staff held regular and effective multidisciplinary meetings to discuss patients and highlighted issues and outstanding tasks.

We observed a huddle which was well attended, and information was shared between different teams. However, there was a mismatch of understanding between the site team and ED team regarding bed allocations. The site team was responsible for managing hospital capacity including emergency admissions. Due to this, patients stayed in ED longer than they had to and blocking cubicles. Staff told us this was a regular occurrence rather than a one off.

We observed good collaboration and communication between all grades and professions within the department itself. Staff told us of cooperative, supportive and appreciative relationships across the department and other parts of the hospital.

Staff referred patients for mental health assessments when they showed signs of mental ill health or depression. We reviewed patients records and found this had been completed.

The trust had set up a project and secured funding for a physiotherapy front door (FDT) service. As part of the standard operating procedure (SOP), a therapist attended the ED board round every morning where they started assessing patients who fit their screening criteria. ED staff could refer patients to the team at this time. As a result of this, the department reported that currently the FDT were preventing on average 164 admissions per month and patients now had access to therapy assessments within 4 hours of admission.

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.

The service had relevant information promoting healthy lifestyles and support at the department. Staff assessed each patient’s health when admitted and provided support for any individual needs to live a healthier lifestyle. There were information leaflets in patient areas, and these addressed appropriate topics including cancer, mental health, nutrition, alcohol abuse and how to access services other than the ED.

A patient we spoke with told us they had been offered to be put in touch with the mental health team and alcohol abuse advice should they require this. Staff also enquired about medicine allergies and explained the side effects.

The service was not meeting the clinical expectations and the expectations of people themselves. Outcomes were not positive and consistent which led to delays in timely care and treatment.

The trust was not meeting the NHS standard of 95% of patients seen within four hours. For example, we reviewed the performance data for the arrive to depart within 4 hours for the last 3 months and found this to be 73% for January, 72% for February and 69% the trust for March 2025. The 12 hour decision to admit breaches were also the highest for the trust when compared with other trusts of a similar size.

The trust carried out an annual programme of repeated audits to check improvement over time. The ED participated in all relevant RCEM audits, some of which included mental health self-harm, sepsis audit, and infection control.

In addition to this, the department took part in multiple national and local clinical audits. There were processes to monitor audit results and make improvements.

A trust wide sepsis audit which was conducted from June 2024 to September 2024 showed 25% compliance in sepsis 6. Following this, the trust had set up a sepsis team which consisted of a sepsis lead and the Adult Sepsis and Acute Kidney Injury Team (ASK) who were responsible for the overall service of sepsis including sepsis guidelines, improving compliance of sepsis 6, audit work and educating staff. The ASK team were also working on quality improvement projects relating to sepsis care. We reviewed the meeting minutes for the Quality and Safety Committee for the month of March 2025 where improvement work in relation to sepsis was discussed.

We looked at the RCEM infection control audit from last year which outlined key areas of development and recommendations with an action plan. One of the recommendations was to increase the availability of side rooms and this had been achieved following the build of the new ED.

The department had an ongoing programme of auditing, which took place daily, weekly and monthly. Audits included patient safety checklists, consent, high intensity user surveillance, corridor care, falls risk assessment and medicines management. We reviewed the trust wide consent audit for July 2024, which showed a compliance rate of 75% and key areas of development which had been identified and actioned.

The trust had carried out a trust wide hip fracture review in 2024 where they were identified as an outlier when compared with other trusts over time. The review highlighted opportunities for improvement and recommendations and was shared with the trauma and orthopaedic and ortho-geriatric leads for the hip fracture pathway for assessment and review of the findings.

The trust utilised a dashboard for oversight of the department and ward patient capacity and used this to identify real time bed moves and support planning of flow. The local ambulance trust system was used in conjunction with hospital ambulance liaison officer (HALO) and Single Health Resilience Early Warning Database (SHREWD) for system wide planning and dynamic conveyancing. Information collected from these were shared via huddles and site meetings and allowed leaders to monitor and improve performance.

To reduce delays to handover of patients from ambulances, the trust had increased senior decision makers including new acute physician in charge (APIC) and implemented a Standard Operating Procedure (SOP) for Medical Assessment Unit (MAU)/ED to support proactive transfer from ED to different services.

The changes made were to increase the number of Emergency Physician's in Charge (EPIC) across the ED, with specific allocation to Majors (trolley) area, including overview of the ‘Rapid Assessment Area'.

The department was in the process of producing a local assessment of national audit results, which aimed to summarise the national findings and where the trust position was relative to national averages. The assessment would also note any recommendations and form an action plan to ensure greater compliance required.

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

Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients' consent. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health.

Patient records clearly highlighted when a patient had a `Do not attempt cardiopulmonary resuscitation (DNACPR)' flag on the system, and staff could access this information easily.

Staff explained consent to parents and young people they saw in line with trust policy. They involved parents when they were able to with a young person's consent and explained when their confidentiality would be limited to protect the young person's safety.

Staff had access to and followed the Children and Adolescent Mental Health Service (CAMHS) liaison referral pathway when referring young people.

Staff had a good understanding of Deprivation of Liberty Safeguards (DoLS), and could clearly articulate how they would assess patients, and ensure their rights were safeguarded.

Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005 (MCA). They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care. The MCA provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that as far as possible people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. We saw a completed DoLS assessment in a patient record.

Staff had received training in relation to the MCA and understood the importance of giving people choice in the support they received. We observed staff always sought people's consent before providing any support.