Cheltenham General 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

Patient areas were safe, clean, well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service managed patient safety incidents well. However, the service did not always ensure the ED was fully staffed or use systems and processes to safely prescribe, administer, record and store medicines.

At our last assessment we rated this key question good. At this assessment the rating remains good. This meant people were safe and protected from avoidable harm.

The service had made improvements since our last visit. Waiting times from referral to treatment and arrangements to admit, treat or discharge patients were now in line with, and better than, the NHS England (NHSE) national standards and the service was no longer in breach of regulation.

We have not awarded this service a score for Safe.

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

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Trust policies and procedures provided staff with guidance for reporting, managing, investigating, and learning from incidents. The trust’s incident reporting and management policy was in line with the requirements of the national patient safety incident response framework (PSIRF) and focused on learning from incidents to provide safer care.

Staff at all levels had a good understanding of how to use incident reporting systems and what to report. Review of incident data showed areas for learning and improvement were identified and action plans written. Incidents were reviewed by governance leads to identify and monitor risks and inform quality improvement projects. Incidents were presented at patient safety review panels and responded to with patient safety incident investigations, multi-professional reviews or quality summits. For example, staff had raised concerns about their safety in the ED and we saw managers were in the process of supplying personal alarms.

There was a culture of safety and learning. Safety events were analysed, investigated thoroughly, and lessons were learned to continually identify and embed good practices. For example, staff had been given training on sexual harassment conduct following incidents and improved handover processes. Managers could articulate the themes and trends of incidents, the actions they had taken to address them and the methods used for feeding back to staff.

There was a violence and aggression policy. Themes across the trust’s 2 EDs for the 18 months prior to our visit showed an increase in incidents of abuse from April (14 incidents) to September 2025 (27) but a decrease from September to December 2025 (8). Violence and aggression were on the corporate risk register due to the risk of physical or psychological harm to patients, relatives, public and staff during incidents involving abusive, threatening and offensive behaviour or physical violence. Staff had access to a trauma risk management practitioner to support staff who may experience traumatic or stressful incidents in the workplace.

Staff told us they felt there was a strong and positive safety culture where staff were open and honest. The service had a duty of candour policy, which set out staff roles and responsibilities regarding openness, honesty and transparency if something went wrong with a patient's care or treatment. Staff were able to explain what they would do if things went wrong, including having honest discussions with patients and their families.

Patients told us they were happy to raise concerns with staff and were confident they would be listened to. Friends and family feedback from patients indicated their anxieties and fears were not consistently discussed. In response, the service introduced a poster prompt “Any worries today?” and signposted patients to support options.

Total attendances to the 2 EDs across Gloucestershire Hospitals NHS Foundation Trust remained stable, similar to pre-COVID-19 figures. However, since March 2025, there had been an increase in the total admission rates across all the trust’s ED services.

On the day of our assessment, by 5pm there had been 92 attendances and no ambulances. Staff adhered to safe systems and processes to deliver care. There was a trust escalation and flow policy. Data showed the average time to triage (initial assessment) improved from 23 minutes in June 2025 to 18 minutes in November 2025. NHS England’s (NHSE) standard for emergency departments’ initial assessment is within 15 minutes of arrival. During triage, nurses directed patients to the appropriate clinical pathways or departments. Following assessment by a doctor, patients who had major illness or injury were directed to the Gloucester ED.

Since our last report in 2019, waiting times from referral to treatment and arrangements to admit, treat or discharge patients were now either in line with or better than the NHSE national standards, ranging from 87.5% in December 2024 to 91.1% in November 2025. The NHS England standard is for at least 78% of patients to be admitted, transferred, or discharged within 4 hours of arrival at an ED.

The NHSE standard for patients to wait no more than 12 hours after decision to admit had been made, was achieved at 99% every month during 2025. The average time from referral to specialty was 81 minutes in 2025.

There were monthly audits to provide assurance that National Early Warning Score (NEWS2) observations were conducted (NEWS2 is a nationally recognised tool to identify deteriorating patients and escalate them appropriately). Observations included sepsis screening and escalation if patients showed signs of deterioration.

Sepsis was identified and managed through the use of the NEWS2 and NICE (National Institute for Health and Care Excellence) guidance. In August, September and October 2025, an average of 55% of patients received a NEWS2 assessment in less than 15 minutes of triage. Data showed 70% of patients with a NEWS2 score of 5 or above (medium risk requiring an urgent review by a clinician) were escalated in accordance with the escalation policy.

There was a quality improvement project to reduce the average time to antibiotic administration in high-risk septic patients. There was also a sepsis project where locked sepsis medicines drawers had been introduced to resuscitation trolleys to allow quick access to key medicines such as intravenous antibiotics.

There were twice-daily nursing safety huddles (meetings) where staff allocation was facilitated by the nurse in charge. Key messages were discussed, including safety alerts, learning from patient safety events, staffing, waiting times compliance, safety checks and safeguarding. Information was also shared with staff in monthly newsletters.

Staff worked hard to establish and maintain safe systems of care in the ED and promote safe transitions after 8pm when the service became an MIIU. Since our last assessment, a large sign was installed outside the ED entrance indicating the service hours. However, some patients remained unclear about what illnesses and injuries could be treated at the department.

Information sharing pathways from external emergency services supported improved patient outcomes. Ambulance and other referring services provided information to the ED for incoming patients. This allowed for check-in, triage, and treatment to be streamlined and for ED staff to monitor flow. Staff managed patients’ records across four electronic patient record systems.

The ED had a clear pathway for supporting people with mental health needs. Since our last assessment, nurses completed mental health risk assessments during triage and patient records we reviewed confirmed these were completed. There was a designated assessment room in the majors’ area for patients presenting with mental health problems. There were signs in staff rooms with information on how to contact the mental health liaison teams including self-harm (8am to 10pm, 7 days a week), older age adults (9am to 5pm, 7 days a week) and alcohol liaison (9am to 5pm, Monday to Friday). There was a learning disabilities nurse available to support the service.

Most patients reported a joined-up approach to providing care and treatment that involved them and their relatives. Patients told us the initial assessment of their symptoms had been timely and treatment initiated where needed.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 had access to safeguarding policies which referenced legislation and best practice guidance. Staff received safeguarding training relevant to their roles and staff we spoke with knew how to identify adults and children at risk of, or suffering, significant harm. Staff understood how to protect children, young people and their families from abuse and the service worked well with other agencies such as the police and the local authority safeguarding teams to protect them.

The service had a safeguarding team that staff could readily access. Staff we spoke with were aware of how to raise safeguarding referrals and knew who the safeguarding lead was in the ED. Staff were able to tell us when they recently completed referrals.

Patients were protected from abuse. There was a violence and aggression policy supporting staff to feel safe at work and for every service user or visitor to have the right to receive care without fear of violence or aggression. The policy included restraint reduction standards.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Patients we spoke with told us they felt safe and if they had any concerns or issues, they would feel comfortable to tell someone.

There were no security personnel in the ED and staff felt a level of vulnerability, especially at night because of a lack of security teams. Reception staff told us they faced violence and aggression from patients. There was no protection barrier between public and staff at the reception desk and no emergency buttons if there was a threat. However, at the time of the assessment, the trust told us a protection barrier had been purchased and was being fitted, and personal alarms were being provided.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We observed staff communicating with patients, so they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. We saw staff had access to a full range of interpreting services and were able to support people with visual or hearing impairments.

Staff used a national triage tool to triage patients to the appropriate services. Generally, most patients were quickly and accurately assessed to determine the urgency of their condition and staff prioritised care based on patients’ needs. Patients we spoke with told us their wait for triage had been timely.

Most patients told us they were informed of why they were being moved between areas in the ED and waiting times had been communicated.

Patients told us they felt safe and supported whilst they were in the ED. They could approach staff if they felt their health was deteriorating and were confident staff would respond to their concerns.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Since our last assessment, clinical areas now appeared clean and were furnished. Domestic staff were present within the ED during our visit.

The equipment and facilities mainly supported the delivery of safe care. However, the environment did not facilitate patient confidentiality as conversations could be overheard during check-in at reception due to the layout of the area.

Prior to the assessment, the service was evacuated due to a building fire alarm following the service’s evacuation policy. Staff monitored patients’ safety through clear lines of escalation and regular checking. Staff confirmed there was a recent fire risk assessment in November 2025.

We observed storage of some chairs blocked access to the relatives' room next to the ambulance doors. However, staff cleared the blockage during our visit to provide access.

There was a separate area for children and their families which was safe and secure and there were toys to keep children occupied.

Patients told us they were well looked after by staff.

The service did not always make sure there were enough qualified, skilled and experienced staff. However, they made sure staff received effective support, supervision and development.

Managers calculated the number and grade of staff required for both ED’s in Gloucester and Cheltenham with some staff rotating between the 2 units. When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels.

The service had about 12 full-time consultants. Current staffing data showed a vacancy rate of less than 1% for all grades of medical staff, the highest vacancy rate (6%) was amongst resident doctors which was below the trust target of 10%. Data showed that nearly 13% of resident doctor and 25% of middle-grade doctors shifts were covered by bank additional duty hours or agency shifts. This indicated the current staffing establishment for resident doctors was less than it needed to be and since our last assessment there was still an over-reliance on bank staff and agency.

The resident doctors we spoke with during our visit had previously worked at the Gloucester ED, most of whom were now working in Cheltenham as temporary medical staff (locums). There was always an emergency department consultant during the day who was the senior decision maker. However, most care was delivered by temporary medical staff, overseen by both substantive and locum consultants during the day. It was not clear what the long-term plan was for recruitment to permanent posts, to create a more sustainable future.

There was adequate 24-hour nursing cover including staff who worked from 4pm to midnight. However, due to pressures at Gloucester ED, nursing staff were frequently sent to the Gloucester ED to work. Service leaders conducted daily risk assessments to identify needs and maintained control of staff allocation between EDs. When necessary, managers supported frontline staff to maintain safe staffing levels. The quality assurance of staffing levels was provided by training and development as well as senior supervision.

There had been a significant effort in recruitment and upskilling of nurses. The trust employed approximately 270 nursing staff, who worked flexibly across both ED sites. Managers had introduced a skills review, which had led to an increase in band 6 (senior) clinical practitioners) and were looking at recruiting paediatric healthcare assistants. However, data showed an overall vacancy rate of just over 16% for all staff which is higher than the national vacancy rate of 6.7%. In addition, the most recent data showed an overall staff sickness rate of 4% for all staff. This was lower than the current national figure for sickness absence within the NHS of 5.3%.

There were safe recruitment practices to ensure all staff, including agency staff and volunteers, were suitably experienced, competent, and able to carry out their roles. There was a suite of policies relating to safe recruitment and all new starters received comprehensive inductions. Staff we spoke to told us they had received thorough inductions which supported them to work effectively in the ED. Nursing staff had mentors who supported them with training needs.

Managers had stopped staff from working permanent night shifts. As the unit was a consultant-led ED from 8am - 8pm and a nurse-led minor injuries and illness unit (MIIU) from 8pm - 8am, staff who were working permanent night shifts were being deskilled. Staff were also rotated between the two EDs because they were being deskilled at Cheltenham as it did not take any major trauma patients.

There was an appraisal policy, and all staff had annual appraisals (how managers check the quality of staff’s work). Current data provided showed ED nursing staff appraisal rates were compliant at over 90%.

There was a mandatory training policy and staff were mainly up to date with training relevant to their roles at the time of the assessment. Overall compliance for all staff was 94% which was higher than the trust target of 90%.

There was a positive culture around nursing education, classes and learning opportunities. We were told there was a culture of supporting staff to develop and progress.

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

There was a trust-wide policy that followed the national NHS infection prevention and control manual (NIPCM) for England. Annual reports went to the board of directors. The trust undertook annual reviews of infection prevention and management. Yearly programmes focussed on continual improvement to deliver safe care. Multidisciplinary monthly cleaner hospital forum meetings were held to review cleaning audits and data, any emerging risks and action identified. The service had a cleanliness rating of 5 stars which was displayed (dated 26 November 2025.)

Staff adhered to infection control principles, including handwashing. Staff observed the uniform policy set out within the service and complied with “bare arms below the elbows” policy. Uniform compliance was audited annually.

Clinical areas appeared clean and we observed cleaning staff conducting a deep clean of a bay following a patient transfer.

Data provided showed the service was over 90% compliant for staff kitchen audits and glove audits from January to November 2025. Hand hygiene compliance audits showed 100% compliance for the 3 months prior to our visit (September, October and November). However, the service did not conduct methicillin-resistant staphylococcus aureus (MRSA) audits. Water jugs were provided for patients in the waiting room but were not monitored for cleanliness or contamination. This lack of oversight meant there was a risk of infection to staff and patients.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

We observed practice and medicines management in the ED. We reviewed medicines administration records and notes. We spoke with department nurses and nursing associates.

Medicines for use in an emergency and antidotes were available in the ED and staff knew how to access these. The service had safe systems for the appropriate and safe handling of medicines. However, we saw that these were not always consistently followed by staff.

The ED was not always supported by clinical pharmacy staff to assist with the safe use of medicines. A clinical pharmacist based at Gloucestershire Royal Hospital (GRH) ED was available during weekdays to help with medicine-related queries. The level of pharmacy support to the ED was not in line with national guidance.

Clinical staff accessed patients’ GP records to review their medical history and current prescribed medicines. However, staff did not always carry out full medicines reconciliation (the process of accurately listing a person’s current medicines when they are admitted into a service or when their treatment changes). Also, staff did not always record the drug-related allergies on the electronic prescribing system.

There were processes to improve people’s access to medicines and expedite discharge to improve patient flow within the ED. For example, appropriately trained staff used patient group directions (PGDs) to provide patients with the medicines they needed. However, we observed some of these printed PGDs were out of date and required review.

Medicines for use in an emergency were available in emergency trolleys. However, staff were not following trust policy and undertaking regular, systematic checks of these trolleys to ensure these medicines were suitable for use when needed. The sepsis trolley checklist had been completed on 8 December 2025. However, we observed there was no record of it being completed between 15 November 2025 and 8 December 2025. This meant there was a lack of assurance medicines and equipment were always suitable and available for use in an emergency. Oxygen cylinders were stored securely. However, warning labels relating to oxygen storage were not installed to meet requirements.

A new electronic system had been recently introduced for staff to record temperature readings in areas where medicines were stored. We saw this new system had not been embedded and daily checks for both room and ambient temperature monitoring had been missed on multiple occasions. This meant the trust could not be assured medicines, including vaccines, were being stored according to the manufacturers’ recommendations and suitable for use.

The service had systems to ensure staff knew about medicines safety alerts and incidents. We saw reported incidents were monitored, reviewed and, where required, changes to practice were implemented.

There was a cycle of medicines related audits. Results were used to support improvement work in medicines optimisation. Work from these audits was presented at directorate meetings.