Great Western Hospital

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our last assessment we rated this key question as good. At this assessment the rating has remained the same.

We have not awarded this service a score for Well-led.

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

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The trust vision was to provide great service for local people at home, in the community and in hospital, enabling independent and healthier lives. The trust set out priorities through their strategic pillars which was outstanding care, valued teams, better together and sustainable future. We spoke with staff who were aware of their visions and priorities.

The trust shared with us their local strategic direction for the year 2025-2028 which included four strategic pillars: outstanding care, valued teams, better together and sustainable future. The trust had a number of initiatives underway to support their journey to carbon net zero by 2040 and had been awarded to Silver "Green" ED accreditation for their efforts to reduce carbon in urgent and emergency care.

The department set up workshops and surveys with their staff teams and volunteers to ensure that they considered all the voices when developing their local strategic direction.

Staff reported the team worked effectively together, with staff across all areas respecting each other and working together to provide the best possible care and treatment to patients. We observed positive and caring interactions between staff and their patients and their relatives who used the service. We also noted good collaboration and communication between ED staff of all grades and disciplines.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told us the departments leadership team were visible and approachable, and well-integrated in the department. Staff felt supported by leaders to develop their skills and take on more senior roles. However, many staff we met could not recall seeing trust executives or non-executive directors in the department or at team meetings to support better care for patients.

The department sat under the division of medicines. At the local ED level, the department shared a manager between UTC and ED and employed a clinical lead and matron for each area. The clinical lead acted as a lead for the medical workforce within the emergency department and a liaison between the ED and the trust management at care group, divisional and executive level. The matron for each area was responsible and accountable for the delivery of safe, high quality patient care in the ED and children’s emergency unit.

Leaders within the department had the integrity, skills and abilities to run the service. They understood and managed the priorities and issues the service faced. The trust ran internal leadership programmes for all staff in a clinical and non-clinical roles starting from band 2s to consultant level. These were delivered with a mix of online learning, online live teaching sessions and face to face sessions.

One of the leadership programmes included a sustainability leadership for greener health and care programme for anyone working in health and care, who wanted to develop their leadership abilities, giving them the tools and knowledge to build a greener, more sustainable health system.

Some of the leadership programmes included the Edward Jenner Programme for those preparing for their first management/leadership role and the Rosalind Franklin for mid-level leaders aspiring to lead in large and complex departments, services or systems.

The People and Culture Committee was led by the deputy chief people officer and met monthly to discuss and review leadership initiatives and the functions that were in place to support the development of leaders and assurances of future plans.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The trust had recently appointed a lead freedom to speak up (FTSU) guardian who was available should staff want to raise any concerns. In addition to this, the trust had 9 volunteer guardians who provided advice, support and directed individuals to the most appropriate channels to ensure concerns were addressed professionally and lead to clear outcomes. Staff were aware of who these were and told us they felt they could raise concerns without fear of reprisal.

Staff had access to the freedom to speak up policy which provided information on how to speak up and what to expect to happen after speaking up.

The Trust Management Committee and the Quality Safety Committee produced quarterly reports which provided an overview of the work of the FTSU guardians, updates from national guardian office and the FTSU service activity over the 6 month period. The report from January 2025 reported the successful appointment of new guardians and the establishment of 3 levels of mandatory training on FTSU.

Data provided to us post inspection showed that the trust had identified inappropriate attitudes or behaviour and bullying harassment to the main theme from last year freedom to speak up review. We reviewed the meeting notes for FTSU quarterly report for the month of January 2025, which contained an action plan to address these and provide improvements and oversight.

The service valued diversity in their workforce. Staff worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff had access to the trust wide equality, diversity and inclusion policy which was in date and due for a review in 2026.

The trust was committed to ensuring that equality and diversity was a fundamental principle in all policies and procedures within the trust and these were effectively promoted and used equitably across the organisation. The trust staff survey working group made up of human resource and people professionals, divisional representatives and the equality diversity inclusion (EDI) lead met monthly to review results, identify trends, and co-develop target initiatives.

Staff received equality and diversity training as part of their mandatory training. Within the equality and diversity policy contained the policy objectives and the arrangements for monitoring compliance of these. Managers worked with human resources and equality diversity lead to develop action plans and ensure compliance.

Each division and department reviewed their staff survey data to address disparities and improve the working life experience of staff. There was also a trust-wide initiative to address discrimination, a divisional EDI working group led by the senior people partner and senior manager to develop local plans to address unprofessional behaviours. The group reported to the trust board and measured organisational performance against national standards and recommendations.

The service had governance processes in place but leaders could not assure that these were always effective as staff did not always report incidents and share this others when appropriate. The department was not meeting expectations such as national standards which meant patients stayed in the department longer than required.

Outcomes for patients were not always positive, consistent and did not always meet expectations, such as national standards. For example, long waits in the department led to untimely care and treatment which impacted the patients' health. On the day of our inspection, we saw a number of elderly patients waiting in the department for several hours who had not been provided with pressure care. Delay in timely assessments can result in severe or fatal outcomes. A review of the departments LFPSE data for the last three months showed that there was an incident where a skin check was not carried out on a patient on admission assessment. The patient was later found to have a 3cm split at the top of their natal cleft and were soaked in urine. However, as staff told us they did not always report incidents it was unclear whether there were other incidences which had not been reported.

The department sat under the division of medicine which contained 69 divisional risks in their risk register. Twenty four of these risks belonged to the emergency department and urgent treatment centre. The risk to patient safety and care for patients who required emergency treatment due to the inability to offload ambulances at the point of arrival due to critical capacity of the trust, ED, and MAU as well as flow throughout the hospital and to system partners was scored the highest and this had been open since 2021.

The risk of increasing waits to be seen as attendances increase, without a review of current staffing model had been in place since 2021 and the department was still not meeting the national guidance and reported staffing challenges at registrar levels and weekends.

Information discussed within various committees fed into the division of medicine board where urgent and emergency care sat. The triumvirate at local level was made up of matron, clinical lead and the general manager who met monthly.

Clinical Governance Meetings were held monthly and were open to all staff. We reviewed the meeting minutes for UTC and ED clinical governance meeting for the month of February and March 2025. They reviewed performance, incidents, complaints and audits and had common themes across the directorate. They investigated serious incidents which happened in the departments and shared learning. However, where incidents had not been reported by staff, this meant there were potential gaps in performance and areas of risk which hadn't been identified, meaning improvements could not be made and risks mitigated.

The department consistently operated systems to ensure they shared information with external organisations effectively, in a timely way, for example, accidents and incidents were reported to the relevant authorities, including the CQC.

There were procedures to safely manage sensitive data which allowed them to maintain people's privacy, dignity and confidentiality. Governance meeting minutes we reviewed showed staff from different areas of the service attended and were involved in discussion about the service and how improvements could be made.

In addition to this, the trust carried out morbidity and mortality reviews in the department and delivered these to staff with learning points and themes which had been identified.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. Staff share information and learning with partners and collaborate for improvement.

The department collaborated and worked in partnership with stakeholders to support the delivery of the service and support joined up care. They shared information and learning with partners to improve the service.

ED staff worked with staff from a local ambulance service to form a rapid assessment review group in order to refine processes within the rapid assessment area. Staff liaised and interacted daily with senior ambulance staff to regularly review any issues or concerns or improvement opportunities between services. In addition to this staff also attended the weekly senior liaison meetings and bi-weekly regional service meetings to identify and develop joint service improvements.

For mental health patients, the department worked closely with a local Mental Health Trust to ensure a joint approach to the provision of mental health care and assessment for patients in the emergency department, including ensuring timely assessment, patient advocacy and risk management.

The department also worked closely with the local police and shared key information which enabled safeguarding and consistency for service users and ensured concerns were identified and acted upon both timely and collaboratively.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcome and quality of life for people. Staff actively contribute to safe, effective practice and research.

Leaders encouraged staff to speak up with ideas for improvement and innovation and actively invested time to listen and engage. There was a strong sense of trust between leadership and staff.

The service used information through incidents, complaints and feedback from patients and reviewed this through several governance meetings to improve the safety and quality of service for patients.

Staff had access to a quality improvement toolkit which outlined the tools and techniques required when taking on a quality improvement project. This included setting aims, establishing measures, identifying changes and testing it.

Post inspection, the trust provided us with details on the improvement projects which were undertaken by the department. Some of these included non-fatal strangulation, first fit clinics and introduction to spiking leaflet.

The trust took part in the Paediatric Emergency Research in the UK and Ireland (PERUKI). Some of the projects included management of elbow fractures in children and ingestion of magnetic foreign bodies.

The department also took part in research and provided a list of publications from 2023 until recently.

One of the recent innovations designed by the department included a female urinal (UniWee) which was trademarked and designed protected with the anticipated commercial production in June 2025.