Cheltenham General Hospital

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We rated the responsive key question as good. We assessed 7 key questions for person-centered care, care provision, integration and continuity, providing information, listening to, and involving people, equity in access, equity in experience and outcomes and planning for the future. People told us medical care staff made sure they were at the center of their care and treatment choices and decisions were made, in partnership with them. This included how to respond to any relevant changes in their needs.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Responses from people we talked to about their experience of their involvement in their own care through the medicine division at CGH was positive. People told us how their partners had been openly involved in conversations around rehabilitation and goal setting. They told us this made them feel ‘very involved’ in their care rather than things being done to them.

People were supported to make decisions in line with relevant legislation and guidance. People told us staff members displayed understanding and non-judgemental attitudes towards them. Two people told us staff involved made them feel ‘human again.’ They also said staff never made them feel anything they asked for was too much trouble. Staff were happy to help them with their personal care.

One person told us they were in the discussion with the doctor about their Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form. The ReSPECT process creates a summary of personalised recommendations for a person's clinical care in a future emergency in which they do not have capacity to make or express choices.

Staff we spoke with understood the relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005 and the Children’s Acts 1989 and 2004.

The process for seeking consent was monitored and reviewed to ensure it met legal requirements and followed relevant national guidance. The trust’s consent policy provided roles and responsibilities for all staff involved in the consent process at CGH.

Staff understood and respected the personal, cultural, social, and religious needs of people. Staff understood how these related to care needs.

Staff explained how they responded when people experienced physical pain, discomfort or emotional distress using nationally recognised tools. The medical care service ensured people were given effective pain relief including ensuring people with a terminal diagnosis who were admitted from home were able to continue their regular home drug routine for pain relief.

People had their nutrition and hydration needs met, including those related to culture and religion. Specialist stroke nurses or Speech and Language Therapists (SLT) conducted swallow assessments and where patients were nil by mouth for a prolonged time, alternative arrangements were made to meet patients’ hydration needs.

Staff had access to dietitian services. The service was able to provide special meals, pureed meals and were skilled in the management of percutaneous endoscopic gastrostomy (PEG) feeding for patients who had suffered a stroke. PEG tubes are used to feed a person straight into their stomach if they have a problem feeding by mouth. Food was also provided to meet religious or cultural needs such as Halal or Kosher.

Staff held a safety brief every morning that informed them which patients needed additional help with red trays used to identify people who required assistance with their meals or needed extra supervision with eating.

Staff had access to translation services if required

Staff understood the relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005 and the Children’s Acts 1989 and 2004.

Staff in oncology understood the importance of informed consent and showed us they checked consent forms and confirmed with the people before starting treatment. We saw staff also continued to check their consent on an ongoing basis in case people changed their mind, or a change had been made to their treatment pathway.

People’s needs were responded to in a timely fashion. Where able, they were encouraged to be as independent as possible.

Those with higher dependency needs were supported by staff to meet those needs in a kind and respectful manner. Individualised care plans were completed for each patient and these included personal preferences and needs, as well as how these would be met by staff.

The services provided by the medicines division reflected the needs of the population served and ensured flexibility, choice and continuity of care. People we spoke with in oncology explained how they were given a choice of appointments for their treatment. Staff used the persons own preferred methods where possible and there were easy read materials available plus information on treatment could be obtained through the focus center in multiple languages.

Services provided reflected the needs of the population served and ensured flexibility, choice and continuity of care. The facilities and premises on Avening ward (chemotherapy) were appropriate for the services that were delivered. The ward had been recently renovated and allowed greater capacity to deliver more sessions of treatment each day. As part of the renovations, skylights had been installed to give the unit more natural light. Staff explained that some types of chemotherapy could be delivered remotely and a mobile unit was also used to allow people who lived in more rural areas to access chemotherapy closer to home records and shared where necessary. The trust took part in national benchmarked audits which showed its compliance with national standards in stroke care. Staff explained that historically some people had told them they had felt lost after discharge from the service as they were transitioning from a period of intense support and treatment back to normal life. In response, staff referred people to the focus centre to access the next steps programme which gave people access to ongoing support groups and activities to help them get used to normal life again. Reasonable adjustments were made so that people with a disability could access and use services on an equal basis to others. Although ward space was limited, there was space for wheelchair users to move around the ward. People on the ground floor oncology ward also had access to a garden area outside and a balcony on the first-floor ward. Staff told us that the medicine division at CGH had support to aid the delivery of care to people in need of additional support, such as dementia champions, dementia symbols and learning disability link nurses. Staff planned for people who needed translation services and quiet areas with phones where telephone translation could be accessed away from any noise and in privacy. Staff explained they did not use family or friends to translate.

The medicines division had a people flow and escalation process policy which referred to national guidance, provided a process for the escalation of concerns and a description of the triggers that would require the implementation of the policy. The escalation process at CGH described the responsibilities of individual managers at each managerial level.

The trust shared plans for future developments to meet the needs of the local community in their document titled ‘Fit for the future for developing integrated specialist health services in Gloucestershire’ in which the medicine division played a significant role. This provided an overall strategic statement, setting out the vision and providing a rationale as to why change was needed and the proposals offered by the trust with a comprehensive timetable and action plan for medical services, including those based at CGH

Staff had access to communication aids to help people become partners in their care and treatment.

People told us staff used people’s own preferred methods where possible and there were easy read materials available plus information on cancer treatment could be obtained through the focus center in multiple languages.

The service identified and met the information and communication needs of people with a disability or sensory loss. This information was stored in the person’s electronic record and shared where necessary. Services were delivered, made accessible and coordinated to take account of the needs of different people, including those with protected characteristics under the Equality Act. People were supported during referral, transfer between services and discharge.

Reasonable adjustments were made so that people with a disability could access and use medical services on an equal basis to others

The medical service had systems to aid the delivery of care to people in need of additional support, such as dementia champions, dementia symbols and learning disability link nurses. We saw dementia symbols above patient’s beds and on whiteboards on wards plus stickers on paper records to alert staff that they were living with dementia and may need additional support.

Staff within medical care complied with the Accessible Information Standard by identifying, recording, flagging, sharing and meeting the information and communication needs of people with a disability or sensory loss. On the stroke wards, specialist stroke nurses made every effort they could to use communication aids for people but also explained the importance of non-verbal cues when people were unable to communicate at all.

Staff used a reporting and reviewing of incidents action card. This provided a rationale and provided details of the process for escalation and the format for follow up discussions of learning points.

Staff followed the trust policy for interpretation and translation which provided information to people on organisations that had been engaged by the trust to provide interpretation and translation services.

People we spoke with in oncology explained they were given a choice of appointments for their treatment.

The trust had undertaken a survey of people’s experience of care in the trust which provided a comprehensive breakdown over each ward, including the medicine division at CGH.

The 17 questions were shared and provided information for the basis of action plans to improve the medical services. The survey had been open for a 2 -month period to gain as many responses as possible. We were shown evidence of actions senior leaders had taken in response to this survey.

People we spoke to told us it was easy for them to access the complaints process to make a complaint or raise concerns, although nobody we spoke with had cause to do so yet. We reviewed the complaints log for the period 12/03/2024 to 24/05/2024 for the medicine division at CGH. During this time, there were 19 complaints recorded of which 10 had been closed. Ten of these complaints were for diagnostic and specialties, all relating to people’s care. However, there was no reference of actions taken from these or if these had been dealt with effectively to identify learning.

People with the most urgent needs had their care and treatment prioritized. People with a suspected stroke were sent to the hyper acute stroke unit where they could access urgent diagnosis and treatment. Flow through the hospital was managed by an onsite team. Transfers between medical wards were discussed at shift handovers and staff shared information about people via telephone to the accepting ward before they were transferred. People were supported during referral, transfer between services and upon discharge.

However, some people were not told the reasons for moving wards. Staff did not always ask people where they wanted to go if they were being transferred to another NHS facility. This was often due to a lack of availability of beds in community hospitals

Staff within medical care made it easy for staff and people to share feedback and ideas or raise complaints and concerns about patient care, treatment and support. This was provided through the trust’s complaints process, staff and people surveys and the availability of a Freedom to Speak Up Guardian. Freedom to Speak Up Guardians support workers to speak up when they feel that they are unable to do so by other routes.

People who used services, those close to them and their representatives were actively engaged and involved in decision-making.

Some people experienced a longer length of stay depending on their discharge plans, especially if they were being discharged to a community hospital as this was dependent on when these beds were free.

The medicines division at Cheltenham General Hospital involved external organisations to help them improve or sustain the care provided to people with mental health or emotional wellbeing issues. This included some external cancer charities and support groups.

People’s outcomes and information about the outcomes of people's care and treatment (both physical and mental where appropriate) were routinely collected and monitored. For example, the service collected data and submitted it to various national audit programmes, such as the National Audits for Medicine Oncology. These were presented to the trust board through the medicines division governance framework and was referred to in the trust’s quality report.

The service participated in relevant quality improvement initiatives, such as local and national clinical audits, benchmarking, (approved) accreditation schemes, peer review, research, trials and other quality improvement initiatives. All relevant staff were involved in activities to monitor and use information to improve outcomes.

The service regularly reviewed the effectiveness of care and treatment through local audit and national audit. The service held regular audit meetings to review performance in people outcomes

The trust had a CGH out of hours policy which described the process for clinical services at CGH, to ensure safe and effective care for people who presented at the hospital out of hours. This plan described the services that were covered, for the overnight period between 5pm to 8am, during bank holidays and weekends.

The trust’s operational policy provided roles and responsibilities for the medical care of persons presenting to the hospital, stating there would be consultant cover from 8am to 10pm during weekdays and 8am to 5pm on weekends with a senior decision maker providing cover up to 10pm.

On the evening of our visit, we saw 7 people being cared for in the Minor Injury and Illness Unit (MIIU) out of hours. This was due to a lack of available beds.

We observed several meetings where the site manager discussed patients with each of the leads for the wards to ensure a safe transfer of patients and to monitor bed availability. The medicine division operated a policy of ring-fencing certain specialty beds and the policy stated: ‘to ensure patients’ safety and outcomes for areas of high risk are not compromised’.

The patient flow and escalation policy provided details of which medical beds at Cheltenham General Hospital were ringfenced and escalation areas that could be used. The service had a procedure and checklist are to aid with the decision-making process.

People who used medical services, those close to them and their representatives told us that they were actively engaged and involved in decision-making. People told us how their partners and loved ones had been openly involved in conversations around rehabilitation and goal setting. They told us this made them feel very involved in their care rather than things being done to them.

The people survey covering all the medical care units and wards we assessed was predominantly positive.

The medicines division at CGH involved external organisations to help them improve or sustain the care provided to people with mental health or emotional wellbeing issues. This included external cancer charities and support groups. Information about the outcomes of people's care and treatment (both physical and mental where appropriate) were routinely collected and monitored.

The medicine division at CGH participated in relevant quality improvement initiatives, such as local and national clinical audits, benchmarking, accreditation schemes, peer review, research, trials and other quality improvement initiatives. All relevant staff were involved in activities to monitor and use information to improve outcomes. The service regularly reviewed the effectiveness of care and treatment through local and national audit.

The medicine division at Cheltenham General Hospital contributed to the trust’s Integrated Performance Report which reported on operational performance, quality and safety, use of resources and workforce. This report collated data from across the division and presented a month-by-month comparison of outcome statistics, from the divisions elective care, cancer, outpatient urgent care, primary care and safe care. The report covered several categories including complaints management, mixed sex breaches, boarded patients and mortality.

The trust had an operational policy for the mental health liaison team for CGH which covered those services provided by the medicines division. This provided policies and procedures for the referral service including out of hours provision, discharge policy, links to other trusts, support for specific groups, such as addiction services, mental illness, or people who self-injured etc. Support was also provided to patients presenting with mental health difficulties either while an inpatient or through the urgent and emergency care department.

There was provision in the policy for multi-agency working with other trusts, staff support and education.

There was evidence of regular local audits being undertaken, which included action points and lessons learnt

People we spoke with felt listened to, respected and had their views considered in all their treatment decisions within medical services. People’s carers, advocates and representatives including family members and friends were identified, welcomed, and treated as important partners in the delivery of their care. People told us this was important to them as sometimes treatment could move at a fast pace and relatives often thought of questions they wouldn’t have considered and recalled conversations they would otherwise have forgotten.

People on the oncology wards told us they had meaningful conversations with clinicians about their planned treatment. Following these discussions, which also involved their families, people were supported to choose the treatment options which gave them the best outcome for them, taking account of their home life and social circumstances as well as medical needs. The people we spoke with felt listened to.

Staff within medical care communicated with people so they understood their care, treatment and condition and any advice that was given to them. We saw staff addressing people by their preferred name plus checking they had understood instructions given to them about using a walking frame.

People were empowered and supported, where necessary, to use and link with support networks and advocacy, so that it had a positive impact on their health, care and wellbeing. This applied to people both going through treatment and coming out of treatment and transitioning back to normal life.

People were involved in regularly monitoring their health, including health assessments and checks, where necessary. People who used services were empowered and supported to manage their own health, care and wellbeing and to maximize their independence. The oncology wards and departments utilized the focus center to ensure people could access all community and voluntary support if they wished.

People’s individual care records, including clinical data, were written and managed in a way that kept people safe. Staff in the medicine division of CGH used electronic records to store all a person’s information. We saw evidence that the quality of these records was regularly audited.

Information needed to deliver safe care and treatment was available to relevant staff in a timely and accessible way. In oncology, nurse specialists were using virtual wards to monitor and store people’s information for people with suspected cord compression. This ensured the information was visible to any other clinicians who needed to see it as part of their ongoing care and treatment. This ensured when people moved between teams, services and organisations, all the information needed for their ongoing care was shared appropriately. The medicine division had systems to identify people with pre-existing needs such as dementia. All wards we visited used a pictorial system to discretely notify staff of each persons’ individual needs. Staff in the oncology team could access advice from the mental health liaison team about what to do if a person attempted to discharge themselves or refused treatment. Staff could access clinical psychologist support so people could be supported to make informed decisions about their care and treatment. The hospital had a dedicated cancer information system which operated alongside the electronic patient record system. Staff had identified an issue with information from the oncology helpline or cord compression service not being readily available to other services and clinicians, so had established a virtual ward system to share the relevant information. Patient records we reviewed in oncology included all multi-disciplinary teams (MDT) involved in people’s treatment. Records also showed clear MDT plans which included other providers to help support the people through their pathway.