Gloucestershire Hospitals NHS Foundation Trust provides acute hospital services from Gloucestershire Royal Hospital and Cheltenham General Hospital. The trust employs more than 8,000 staff.
We carried out an unannounced focused inspection of Cheltenham General Hospital urgent and emergency care services (also known as accident and emergency - A&E) and medical care services (including older people’s care) between 8 and 9 December 2021. We had an additional focus on the urgent and emergency care pathway across Gloucestershire and carried out a number of inspections of services across a few weeks. This was to assess how patient risks were being managed across health and social care services during increased and extreme capacity pressures.
As this was a focused inspection at Cheltenham General Hospital, we only inspected parts of five our key questions. For both core services we inspected parts of: safe, responsive, caring and well led. We included parts of effective in medical care. We did not inspect effective in emergency and urgent care at this visit but would have reported any areas of concern.
The emergency department was previously rated as good overall. Medical care was previously rated as good overall with responsive as requires improvement.
For this inspection we considered information and data on performance for the emergency department and medical care. This inspection was partly undertaken due to the concerns this raised over how the organisation was responding to patient need and risk in the department and the wider trust in times of high demand and pressure on capacity. We were concerned with waiting times for patients and delays in their onward care and treatment.
We looked at the experience for patients using urgent and emergency care and medical care services in Cheltenham General Hospital. This included the emergency department but also areas where patients were cared for while waiting for treatment or admission. We also went to wards where patients were admitted for further care. This included the emergency department, medical wards and areas where patients in that pathway were cared for while waiting for treatment or admission. We visited services and departments that patients may encounter or use during their stay. We also went to wards where patients from the emergency department were admitted for further care. This was to determine how the flow of patients who started their care and treatment in the emergency department and those cared for on medical wards, was managed by the wider hospital.
A summary of CQC findings on urgent and emergency care services in Gloucestershire
Urgent and emergency care services across England have been and continue to be under sustained pressure. In response, CQC is undertaking a series of coordinated inspections, monitoring calls and analysis of data to identify how services in a local area work together to ensure patients receive safe, effective and timely care. On this occasion we did not inspect any GPs as part of this approach. However, we recognise the pressures faced by general practice during the COVID-19 pandemic and the impact on urgent and emergency care. We have summarised our findings for Gloucestershire below:
Provision of urgent and emergency care in Gloucestershire was supported by health and social care services, stakeholders, commissioners and the local authority. Leaders we spoke with across a range of services told us of their commitment and determination to improve access and care for patients and to reduce pressure on staff. However, Gloucestershire had a significant number of patients unable to leave hospital which meant the hospitals were full and new patients had long delays waiting to be admitted.
The 111 service was generally performing well but performance had been impacted by high call volumes causing longer delays in giving clinical advice than were seen before the pandemic. Health and social care leaders had recently invested in a 24 hour a day, seven day a week Clinical Assessment Service (CAS). This was supported by GPs, advanced nurse practitioners, pharmacists and paramedics to ensure patients were appropriately signposted to the services across Gloucestershire.
At times, patients experienced long delays in a response from 999 services as well as delays in handover from the ambulance crew at hospital due to a lack of beds available and further, prolonged waits in emergency departments. Patients were also remaining in hospital for longer than they required acute medical care due to delays in their discharge home or to community care. These delays exposed people to the risk of harm especially at times of high demand. The reasons for these delays were complex and involved many different sectors and providers of health and social care.
Health and social care services had responded to the challenges across urgent and emergency care by implementing a range of same day emergency care services. While some were alleviating the pressure on the emergency department, the system had become complicated. Staff and patients were not always able to articulate and understand urgent and emergency care pathways.
The local directory of services used by staff in urgent and emergency care to direct patients to appropriate treatment and support was found to have inaccuracies and out of date information. This resulted in some patients being inappropriately referred to services or additional triage processes being implemented which delayed access to services. For example, the local directory of services had not been updated to ensure children were signposted to an emergency department with a paediatric service and an additional triage process had been implemented for patients accessing the minor illness and injury units to avoid inappropriate referrals. Staff from services across Gloucestershire were working to review how the directory of services was updated and continuing to strengthen how this would be used in the future.
We found urgent and emergency care pathways could be simplified to ensure the public and staff could better understand the services available and ensure people access the appropriate care. Health and social care leaders also welcomed this as an opportunity for improvement. We also identified opportunities to improve patient flow through community services in Gloucestershire. These were well run and could be developed further to increase the community provision of urgent care and prevent inappropriate attendance in the emergency departments.
There was also capacity reported in care homes across Gloucestershire which could also be used to support patients to leave hospital in a timely way. The local authority should be closely involved with all decision-making due to its extensive experience in admission avoidance and community-based pathways.
Summary of Gloucestershire Hospitals NHS Foundation Trust - Cheltenham General Hospital
- Staff understood how to protect patients from abuse and acted on any concerns.
- The services mostly controlled infection risk well. Areas we visited were visibly clean and most staff wore personal protective equipment in line with trust policy.
- Patients had an assessment of their infection risk and other clinical risks on arrival at the emergency department and were treated according to their priority of need. Those who needed urgent care received it.
- Managers had reviewed staffing needs and increased the total number of nurses and medical staff recruited. Bank and agency staff were used to fill gaps in the rotas but some shifts could not be filled. Managers were continuing recruitment processes for new roles.
- The services mostly had enough medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Locums were used to fill gaps in medical rotas and managers ensured senior staff were available on each shift.
- Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care. Key services were mostly available seven days a week to support timely patient care.
- Staff were empathetic and caring when treating patients in the emergency department and demonstrated an understanding of how patients may be feeling when receiving treatment. Patients felt informed of their treatment choices and praised staff for care they received.
- The services were inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers.
- Managers risk assessed, adapted and rearranged services at times of extreme capacity pressures to help staff provide safe care and treatment for patients. Staff worked hard to provide care and treatment for patients who stayed in the emergency department longer than anticipated due to capacity pressures on the hospital.
- Leaders and teams used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact. Staff contributed to decision-making to help avoid compromising the quality of care.
- Managers demonstrated the skills and abilities to run the services. They understood and managed the priorities and issues the services faced. Level of capacity pressure for the service was communicated to executive leaders and across the trust. They were supportive and caring for patients and staff.
- There were risks of patients waiting a long time for treatment at the time the emergency department changed to a minor injuries and illness unit. This was particularly when patients were cared for overnight in the department because there were no available inpatient beds in the hospital. In addition to this, the lack of administration support at night sometimes took staff away from providing patients with clinical or nursing care.
- The design, maintenance and use of facilities, premises and equipment in medical care services did not always keep people safe. The use of temporary bed spaces for patients was recognised as not ideal, but in the circumstances was being as safely managed as possible.
- There was no ready clinical oversight of children who were waiting to be seen in the emergency department. Children waited in a designated area which was separate to the adult waiting area. However, they usually attended with a responsible adult and could call for assistance using an alarm bell if they needed to.
- There were not always enough nursing staff with the right qualifications and skills to cover the planned rotas for each shift in the services. However, managers regularly reviewed staffing levels and skill mix to maintain patient safety as much as possible.
- Capacity pressures meant not all patients received treatment promptly across both services, but they were assessed quickly for risk on arrival and prioritised for treatment. A major part of the problem with access to beds for patients in the emergency department, was from the high number of patients who were medically fit to be discharged from hospital wards. They were waiting for further social care support to enable their safe discharge.
- In medical care, patients were sometimes moved between wards and sometimes at night, in order to admit them to the right place once a bed became available. Some patients were needing longer stays while they awaited treatment.
- Some staff in the emergency department felt they were not always valued and supported by their managers or other colleagues across the hospital. They felt vulnerable to potential violence and aggression from patients attending the minor injuries and illness unit at night. They were aware of the protocol to request support from portering colleagues. These colleagues were not always available immediately when needed.
- Some staff felt senior and executive visibility and support was limited. Senior teams acknowledged they were not physically present at Cheltenham General Hospital as much as they would have liked and stated the extreme pressures at Gloucestershire Royal Hospital had taken priority. Staff morale in the services was low due to the immense and unrelenting pressures which had been ongoing for a number of years.
How we carried out the inspection
At Cheltenham General Hospital, we spoke with 23 patients and their families, 27 staff, who included nursing, medical, administration staff and service leads. We observed care provided, reviewed relevant policies, documents and patient records.
You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.