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. We also checked people's liberty was protected where this was in their best interests and in line with legislation.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained the same. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of the legal regulations relating to relation to safe care and treatment.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff did not always listen to concerns about safety and did not always investigate and report safety events potentially leading to delays in incident reporting and identifying and embedding good practice

Staff could describe the process for reporting adverse events using the electronic system. However, they told us that in the last 2 years the reporting system had had many additional fields added to it. It now required information which was not relevant to the incident or was difficult to find. This made it difficult for staff to complete an incident report. They were encouraged to use the system, but sometimes lacked the time to do so, and did not always identify when an incident should be reported. For example, staff told us about how bed pressures had led to patients being treated in corridors, or incidents with medicine errors. The staff involved had not reported these issues as incidents, therefore opportunities to improve areas of risks were missed.

We reviewed the emergency department clinical governance meeting notes for the month of February and March 2025. These showed evidence of incidents being reviewed and learning from incidents being shared.

As part on our ongoing monitoring of the service, the trust notified us about a Never event which involved a nurse administering an oral medication via a cannula. Following this, the department had undertaken swift actions and shared immediate learning.

The department held monthly teaching sessions for the Urgent Treatment Centre. The next session was about shoulder joint and scheduled for May 2025.

Incident reporting policies and procedures were available through the trust’s intranet to guide staff. The trust used the patient safety incident response framework (PSIRF) and learning from patient safety events (LFPSE) to review incidents and discussed via clinical governance meetings as an opportunity to put things right, learn and improve.

For example, for the month of February 2025, the department had reviewed an unexpected harm of a patient and this included a thorough investigation, an action plan and shared learning.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong.

The service did not always maintain safe systems of care and manage or monitor people's safety which made it difficult to recognise who their sickest patients were. Delays in discharges caused a knock-on impact to transfer to wards which meant patients remained in the department for longer than required.

Staff kept detailed records of patients' care and treatment. Records were clear, up to date, stored securely and easily available to all staff providing care. We reviewed 20 sets of patient notes. All were of good quality from both the nursing and medical team input. They were clearly inputted and had timely reviews of patients. The safety checklist was completed each hour for all those patients we reviewed. We reviewed medicine records which showed these were given in a timely manner and charts properly completed. When people were prescribed an antimicrobial for a possible infection, the clinical indication, dose and duration of treatment was documented in their clinical record.

However, staff told us they patient records could be disjointed. For example, clinical observations were recorded on a separate system to the rest of the patient information which meant it was difficult for clinicians to recognise who the sickest patients were. We found this to be the case on the day of the inspection as the nurse in charge did not know who the sickest patient was when questioned.

Staff in ambulatory majors told us they had difficulty accessing the observations screen as this was recorded on a different system. Staff told us they often did not know when observations needed to be repeated.

Trust data we reviewed for time to initial triage assessment within the national standard of 15 mins, had gone down slightly, with performance just below at 53% in March 2025 compared with almost 57% in February and 63% in January 2025, with an average triage time of 21 minutes. However, a new initial assessment process had been introduced in 2022 whereby patients were rapidly assessed by a senior nurse (clinical navigator) as soon as they entered the department. This took place before their details were entered on to the department's computer system and so the speed of assessment could not be recorded. We observed this process throughout our inspection and found it to be safe and effective. Patients told us they appreciated the rapid attention they received.

The department had several workstreams which looked at performance to improve productivity and efficiency across the system. We reviewed the meeting minutes for the patient quality subcommittee for the month of February 2025 and saw evidence of this being reviewed and discussed.

The trust reported an increase in ambulance handover delays over the last 6 months which impacted patient safety and experience within the department. The department was working on a UEC programme to reduce the length of time patients remained in ED. However, during the assessment we saw a patient who had been in the department for 18 hours with no estimate time of discharge. Another patient had waited in the chair for 11 hours before a full assessment by a doctor. We also saw patients being cared for in the corridor.

There were patient pathways for staff to follow, for example, staff had access to and followed the urgent treatment centre (UTC) suspected cancer referral pathway. This had 7 steps to follow if patients met the criteria for the pathway. This also included the contact details for members of the multidisciplinary team (MDT) depending on the area of cancer. Staff also had access to sepsis guidance.

The department conducted senior nursing reviews for patients who remained in the department for 12 hours or more. These reviews occurred at 12-hourly intervals and involved an assessment, which included 4 key questions aimed at providing a quick patient quality and safety check and the opportunity to escalate any patient safety concerns within the department. The department had identified 24 patients who had raised 2 or more concerns during these reviews from November to January 2025 and were in the process of investigating these to identify learning and implement changes as a result if required.

The trust had developed a number of clinical pathways into different specialities. These included the main adult ED pathway, main paediatric pathway and Medical Assessment Unit (MAU)/Same Day Emergency Care (SDEC) medical pathway. However, due to increasing demand and patient needs on wards, there were delays in discharges, which caused a knock-on impact to transfers to wards. As a result, patients remaining in the department for longer and delaying other patients from being seen and not receiving timely care and treatment.

In addition to this, the trust had an urgent and emergency (UEC) transformation workstream which looked at the front door streaming and supporting flow throughout the department.

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 knew how to recognise and report safeguarding issues and knew who to escalate their safeguarding concerns to. The trust had a designated safeguarding lead who staff had access to for advice and support.

The ED safeguarding lead nurse provided a key link between ED and children's emergency unit staff and the trust safeguarding team ensuring key updates and support were provided and communicated. The children's safeguarding team worked closely with the Children Emergency Unit (CEU) nurse manager when required to escalate safeguarding concerns.

Staff received training specific for their role on how to recognise and report abuse. The training compliance data for medical and nursing staff showed that the overall mandatory training rates for level 2 and 3 were above target of 90%. All staff we spoke with said they had received safeguarding training at a level appropriate to their role.

The trust had a safeguarding adults at risk and safeguarding children and young people policy. This provided staff with guidance on how to identify possible abuse and the processes to follow if they needed to raise a safeguarding concern. Both policies were in date and reflected current legislation and guidance.

Staff followed safe procedures for children visiting the department. Access to the paediatric waiting room was provided by staff at the reception after a brief assessment of the patient. Access to ED was via a door buzzer system and staff carried electronic passes to gain entry.

Data provided to us post inspection showed staff had followed trust policies and had made 56 referrals to the local authority in the last quarter.

The service did not always provide appropriate care and treatment to ensure people were safe and staff were not always aware of risks to vulnerable and very sick patients.

The trust had policies, processes and risk assessments in place to manage risks and emergencies. Staff used risk assessment tools to keep patients safe and were trained in least restrictive restraint.

We attended the 3pm bed meeting, the main purpose of which was to maintain oversight of the activity flow within the ED. We saw that actions from the lunch time meeting were reviewed on the day of the inspection. There was a rapid discussion regarding the current position within the ED, and a reminder to carry out duty of candour to patients receiving care in the corridor. pressures. This was attended by the IDF silver (a rota made up of the matron, general manager, unit manager) and a divisional representative.

Staff explained how patients were triaged by triage nurses and demonstrated how they used the National Early Warning Score (NEWS) tool for adults and Paediatric Early Warning Score (PEWS) for children. The tools enabled staff to identify deteriorating patients quickly and escalate them appropriately.

Clinical observations including NEWS were recorded on a separate system to the rest of the patient records. For example, on the day of the inspection we saw staff had recorded a high blood sugar level of 20.3 for a patient on paper. This information was not transferred to the electronic record, therefore the team of nurses looking after this patient for the next 18 hours were unaware of this risk and had not monitored this. When asked to repeat it, this had now increased to 24.2mmol/L. A blood glucose level above 15mmol/L is considered hyperglycaemia. Hyperglycaemia is having too much glucose in your blood.

This was raised with the team during feedback. Following this, the trust had increased senior leadership visibility and increased targeted audit spot checks in the ambulatory area. Additional actions including prioritising the allocation of a band 7 to ambulatory areas particularly during times of high demand had taken place.

We observed a number of patients, some very elderly who had been waiting since 1am. We did not see any pressure area care being given to patients who had been sitting in chairs for over 12 hours meaning people were at risk of skin breakdown. The aim of pressure are care is to maintain healthy skin and this prevent breakdown and development of pressure ulcers.

Post inspection, the department told us contingency measures were in place for patients at increased risk such as those with frailty, advanced age, or reduced mobility where prolonged waiting may impact skin integrity.

The trust had carried out a review of the incidents reported for ED which identified pressure ulcers upon admission being the most frequently reported incident. To address these issues, the team had initiated some improvement work with a local ambulance trust with the aim of implementing measures that mitigated the risk of patient deterioration due to extended wait times and continued to monitor it closely. There were also 2 patients in the waiting rooms who were receiving IV infusions. On the day of the inspection we saw the waiting room was at its maximum capacity and often overflowing at times. Infusions need to be carefully monitored by nursing staff, and this was not possible in a waiting room.

The trust reported a compliance of 25% in sepsis 6 from June 2024 to September 2024. As a result the trust had initiated improvement projects to improve overall compliance. The Sepsis 6 is an internationally accepted management bundle that, when initiated within one hour of identifying sepsis, can reduce morbidity and mortality.

We observed a verbal handover at shift changes and noted a lack of detail regarding patients diagnosis, particularly where they had been waiting more than 4 hours. This created a potential risk of patients not receiving appropriate treatment and care.

The service had 24-hour access to mental health liaison and specialist mental health support. However, face to face assessments only took place during the weekdays from 9am until 11pm. Outside of these hours and during weekends, assessments were carried out on the phone. This did not allow for a complete assessment to take place especially for patients who may have difficulty speaking on the phone due to cognitive or sensory difficulties.

All patients who attended the department underwent triage and initial investigations. This was carried out by a triage nurse who determined whether investigations were needed or if the patient needed to be escalated to majors or resus areas depending on their needs.

The service did not always detect and control potential risks in the care environment.

The design of the environment mostly followed national guidance. However not all areas within the department were suitable for their purpose. We saw patients being cared for in the corridor next to the majors area.

The department had a 4-bedded observation unit which was a short stay observation area for patients who needed longer treatment but did not warrant full admission to the main hospital. This included ongoing treatment, observation or observation whilst waiting for results. Whilst the unit was not a designated mental health unit, it was often used for patients who present with a mental health distress.

Staff working in this unit understood how to undertake best interest decisions, with doctors using a mental health triage form. This also identified which patients were most at risk and also identified the level of support required for each patient. However, we identified a patient who was designated as high risk, who could not be accommodated within the mental health unit but was in the general wating area. This was due to limited number of beds in the unit. We saw this patient was being monitored every 15 minutes but was not being treated within the appropriate area.

Although there were concerns around the mental health unit in relation to mixed sex accommodation, the unit was compliant with the trust ‘delivering same sex accommodation policy’ as the unit of 4 beds was divided into 2 bays of 2 beds with a solid partition wall and corridor curtain. Each bay had its own shower and toilet which ensured bays could be occupied separately by male or female patients.

It was not possible to have private or confidential conversations with patients in the unit. However there were quiet rooms situated within the department which could be used if required.

Staff had access to the equipment they required to keep patients safe and did not report any shortages in environment. We spoke with a range of staff who confirmed that when equipment broke, they had access to replacement equipment. Facilities and equipment were well maintained safe and staff managed clinical waste well.

The trust had relocated to a new Emergency Department in July 2024 followed by the move into the new Children’s Emergency Unit (CEU) in early November. The new area consisted of an Urgent Treatment Centre (UTC), Majors, adult resuscitation, ED observation ward and a separate children’s AE department.

The department also had a Rapid Assessment (RAT) area and an ambulatory majors area. The RAT had 3 cubicles and was used to assess and triage patients who were brought in by ambulance. These patients were then moved to an appropriate area within the department.

Self-presenting patients arrived at the main emergency entrance where a clinical navigator carried out a brief assessment and directed them to the correct area of the department. The department was easy to find and well signposted. We found the entrance to be visibly clean and tidy. The reception staff also sat at the main entrance and signposted patients to where they needed to be.

The waiting rooms within each area had a screen which displayed the waiting times. Patient had access to drinking water and plenty of chairs to sit on.

The children’s CEU waiting area was clean with bright surroundings. Child friendly activities were provided and there was charging points for electronic devices. In addition to this, the children’s department had a sensory room, an infant feeding room and a ligature free toilet.

Equipment and curtains were visibly clean and ready to use. All equipment was well maintained, and safety checked.

There were systems which ensured clinical waste, including sharps, was appropriately segregated, and disposed of. During our inspection we observed sharps bins were correctly assembled and labelled in line with national guidelines.

Clinical staff knew where to find the equipment they needed to respond to an emergency and had received appropriate training to enable effective use of it. Resuscitation equipment was readily available and easily accessible. The hospital had systems to ensure it was checked regularly, fully stocked, and ready for use.

The trust carried out environmental risk assessment. Level of risk was identified by a colour code system of red, amber and green (RAG) level and whether additional controls were required.

The service did not always have enough staff to provide care and treatment to patients. Staff did not always receive appraisals and the service was not meeting the trust target.

Standards for children in the emergency care setting, from the Royal College of Paediatrics and Child Health (RCPCH), which recommends every emergency department treating children must be staffed by 2 registered children's nurses. The department currently had 6 whole time equivalent (WTE) and was not meeting the national guidance of 10.4 WTE. In order to mitigate this, the trust had employed a band 7 management post and were working towards developing a team of specially trained adult nurses to work regularly in the CEU. Bank staff were used to mitigate the risks whilst this team was being developed. One of the priorities of the integrated front team was to recruit to nurse staffing uplift in CEU and develop a workforce plan.

We spoke with department leads who told us there were staffing challenges at registrar level and weekends. We reviewed the staffing for ED for the month of March 2025 and found there were 7 days where medical staffing was below minimum standard. Two of these days were weekends. The risk of increasing waits to be seen as attendances increases without a review of current staffing model was one of the open risks in the front door services risk register. There was an ongoing review of UTC attendances in preparation of business case for additional workforce and review of the medical workforce within the UTC. The department was also covering staffing gaps with locums.

Post inspection we were provided with the data for shifts filled and unfilled for adult and paediatric nurses. For adult nurses, in the month of January, in ED there were 80 unfilled shifts, 65 in February and 84 in March. We also reviewed the nursing rota for the last 3 months which showed that there were 9 days where the department did not meet their nursing staffing model. Shifts that were not adequately staffed may have resulted in patients having a delay in treatment and care.

The department used their bank staff to fill shifts. Staff vacancy rates and sickness rates for the period September 2024 to March 2025 was worse for nursing staff. For example the sickness rate for nursing staff for the month of January and February 2025 was 8% and 6.8% whilst the rate for medical staff during the same period was much lower and within expectations.

Appraisal compliance was low for nursing, medical and UTC staff and did not meet the trust target of 85% for February and March 2025. Employee appraisals are an important element of performance management to improve organisational efficiency by ensuring that individuals perform to the best of their ability, develop their potential and identify any potential areas for improvement.

Supervision was provided for staff by clinical practice educators. Staff described being well supported by managers who understood the pressures of their roles.

Staff were trained for their roles. We spoke with a range of staff who described additional training and qualifications they had undertaken which supported their role and development. The department reported an overall mandatory training compliance of 80.7% for emergency medical staff, 91% for nursing staff and 86.6% for urgent treatment staff.

International staff spoke positively about their induction, and their welcome to the trust. They had equal opportunities to career development opportunities and were encouraged to apply for developmental positions. Staff told us they received annual appraisals to discuss career developments but also had daily opportunities to speak with senior staff about opportunities to progress.

Staff received checks of their competency to ensure they carried out their roles safely. Staff working in the paediatric department completed the national nursing competencies for caring for babies, children and young people in hospital. This included foundation, level 1 and level 2 in paediatric critical care skills.

The trust had also extended paediatric competencies for staff working in the CEU as an extension of the NMC competencies to provide clear departmental standards along with career progression, facilitation, consistency and continuity.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The department controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean and had access to the guidance and support from the infection control team if needed.

There were adequate hand washing facilities within the department. We observed staff maintaining good hand hygiene on the day of the inspection.

Staff adhered to the 'bare below the elbows' policy when providing care and treatment. Disposable aprons and gloves were readily available. Staff used them when delivering care and treatment to patients to reduce the risk of cross infection.

Patients we spoke to on the day of the inspection told us that staff always had personal protective equipment (PPE) on and washed their hands.

We saw evidence of cleaning; cleaning staff were visible in the department, and they used appropriate signage to show when areas (floors) were wet.

The department carried out infection prevention and control audits on a rolling programme over the year. Hand hygiene audits were carried out as part of the infection control audit program. The department reported a compliance of 100% for ED, 87% for CEU and 95% for UTC for March 2025.

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

There were clinical guidelines and resources available to help aid in the prescribing of drugs, particularly in the paediatric unit, relying on the nearest specialist children's hospital guidelines. Storage of high-risk stationary such as paper private hospital prescriptions were stored securely and monitored to ensure they were used correctly. Medicine histories and allergies were clearly documented on patient notes.

Storage of medication including controlled drugs and medical gases were appropriate and safe. Refrigerator temperatures were monitored regularly in most cases.

Staff worked with the appropriate training and skills for their roles, and the governance structures such as patient group directions (PGDs) were in place to ensure staff worked with the appropriate authorisations. PGDs are written instructions to help you supply or administer medicines to patients, usually in planned circumstances.

Emergency trolleys were stocked and checked regularly with evidence of this seen to be the case. Pharmacy staff supported the department with stock management and incident investigation and there was a dedicated emergency department pharmacist.