Cheltenham General 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

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. However, governance processes did not always escalate and mitigate risks.

At our last assessment we rated this key question good. At this assessment the rating remains good.

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.

There was positive feedback from staff and managers regarding culture and implemented changes within the ED. There had been an increase in senior oversight and presence, professional role modelling and increased staffing and support as well as engagement. This had improved the culture, though senior staff were aware there was still more to do to embed the change.

There was a good safety culture where events were investigated, and learning was embedded to promote good practice. Staff said raising concerns was encouraged and valued.

Leaders had a shared purpose, strove to deliver, and motivated staff to succeed. We met a leadership team who supported each other well. Generally, there were high levels of satisfaction amongst staff, despite the challenges they faced.

The trust had a 5-year strategy setting out their future vision, direction and strategic priorities for the years 2025 to 2030. It acknowledged the significant strain on both EDs. A key area of focus for emergency care was supporting the vulnerable and homeless patients when they presented in ED.

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 they felt supported by managers and had opportunities for development. Managers were visible and approachable. Leaders of the service were knowledgeable about the issues and priorities of the service and worked for change and improvement when needed. They recognised where the service needed to be improved and were working to make improvements. They focused on staff wellbeing and ensured a culture promoting good practice, good quality care and aspired to provide safe care and treatment.

There was a triumvirate leadership structure with medical, nursing, and operational leads. There was a strong, committed and capable leadership team in the ED. The leadership team had the skills, experience and knowledge to lead the ED effectively and with credibility. They were open, honest and willing to learn and improve.

Senior leaders were aware of the impact the crowded ED had on staff and that this increased stress. There were support services, and actions to support culture had been implemented. However, leaders acknowledged there was still more to do.

Leaders had effective support and opportunities to develop and maintain their skills. The roles of staff and leaders were clear, and they understood their responsibilities and accountabilities.

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

The service had a freedom to speak up (FTSU) policy and established FTSU arrangements. Staff were aware of how to raise concerns with FTSU guardians who worked alongside the leadership teams. There was a FTSU poster in the staff room with contact details for staff to raise concerns or ideas for improvement.

Leaders encouraged staff to raise concerns and promoted the value of doing so. However, not all staff felt empowered to speak up or thought their concerns would be listened to.

When something went wrong, people received a sincere and timely apology and were told about any actions being taken to prevent the same happening again. We reviewed learning responses which showed duty of candour was completed appropriately.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

We identified governance issues which mainly impacted Gloucester EUC. At Cheltenham the impact was low as it was a smaller department.

Governance systems and meeting structures had been reviewed. There was a set agenda of what was discussed at directorate level in governance meetings to ensure essential information, such as learning from incidents and complaints, was shared and discussed. Staff knew about governance processes and contributed to improvement actions. Weekly harm hubs reviewed incidents for harm, themes and improvement opportunities. There was a process for escalating concerns to senior management. Information was disseminated to staff for awareness and action using a variety of meetings.

Senior leaders for the emergency department worked across both Cheltenham and Gloucester sites. They told us this brought a cohesiveness across both departments. They had held engagement events to allow staff to share concerns as well as make suggestions for improvements. From this they created an ‘Emergency Department Pact’ which staff have signed up to. This covered culture and civility, and being responsive to each other. We heard about improved patient and staff experiences over the last six months.

The team also held monthly quality and performance meetings, which included a broad spectrum of topics, including patient experience, and positive stories to be celebrated.

The leadership team had created working groups within the department to address issues raised, enabling the teams to have ownership of issues raised, and shape the way these were addressed.

The hospital had processes to monitor performance and quality against national targets and standards.

Leaders at Cheltenham ED confirmed it was difficult with patients moving between sites, as the Cheltenham site changed to a minor injury unit at 8pm, which meant some patients would go to the Gloucester ED, and then need to return to Cheltenham hospital the following day.

There were often patients waiting for beds. Doctors expressed concern that they were not well supported by other specialities in the hospital, and told us there was no incentive for these specialties to change their practice to collaborate and help staff and patients in the ED.

The service could not be assured practice was in line with best practice. The service did not always have complete and effective audit programmes to manage safety and quality. The service conducted audits to monitor the standards of record keeping but did not include management of pain in adults and children. There were some associated action plans, but the system was not as effective as it could be because some audits were not completed. For example, the service did not fulfil MRSA audits.

However, departmental risks were monitored every month, with leaders having monthly meetings with risk leads. We saw that risk assessments were up to date.

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

Staff and leaders now better understood their duty to collaborate and work in partnership with people, other organisations and services, so services work seamlessly for people. They shared information with partners. 

The service worked well with other agencies such as the police and the local authority safeguarding teams to protect children and adults.

Occupational therapy support for ED was provided by a community assessment team (CAT). The CAT team consisted of occupational therapists, physiotherapists and support workers. They were employed by a local community NHS trust and worked in partnership with the EDs. Their purpose was to identify patients who could be treated at home but needed additional support. They could review patients on the electronic patient systems and negotiate with clinicians what care was needed and how it could be provided to avoid an unnecessary admission. For example, administration of intravenous antibiotics at home. They were keen to support patients at end of life to be cared for at home if that was the patient’s choice. The team also helped learning disability and cerebral palsy patients to be cared for in the most appropriate place rather than spending too much time in ED.

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

Staff focused on continuous learning, innovation and improvement across the organisation and the local system. They encouraged creative ways of delivering equality of experience, outcome, and quality of life for people.

Staff were given the time and support to develop opportunities for improvements and innovation and this led to improvement in care delivery. This was managed through weekly simulation training on a variety of scenarios.

The service provided a list of quality improvement projects that were currently being undertaken or had been completed. Staff were usually positive about improving services and work had been achieved through the improvement plan. We saw examples of improvements made by the service regarding completion of the ED safety checklist. This was for the management of patients presenting with or developing sepsis in the ED. Also, for the clinical flow of patients who presented through triage and ambulatory patients who attended by ambulance and were categorised as priority 2. However, managers recognised there was further work to be done. For example, due to a required area in ED being unavailable because of demand pressures, 1 project did not have a planned start date.

There were ongoing discussions with paediatric consultants across the trust sites regarding the commencement of paediatric early warning score (PEWS) audits in line with guidance from “Royal College of Paediatrics and Child Health (RCPCH).