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Gloucestershire Royal Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 19 June 2015

Gloucestershire Royal Hospital is one of two district general hospitals run by Gloucestershire Hospitals NHS Foundation Trust. It is an acute hospital with 683 beds. It provides urgent and emergency services, medical care, surgical care, critical care, maternity and gynaecology, services for children and young people, end of life care and outpatient and diagnostic imaging services. It provides specialist cancer care to patients from Gloucestershire, Worcestershire and Herefordshire as the hub for the three Counties’ Cancer Network

We inspected this trust as part of our in-depth hospital inspection programme. The trust was selected as it was an example of a low risk trust according to our new Intelligent Monitoring model. The inspection took place with an announced inspection 10–13 and an unannounced 20 March 2015.

Overall, Gloucestershire Royal Hospital was rated as requiring improvement. We rated it as good for caring and as requiring improvements in safety, effectiveness, being responsive to patients’ needs and being well-led. Overall, critical care was rated as outstanding. Maternity and gynaecology and services for children and young people were rated as good with the remaining core services rated as requiring improvement.

The trust’s services are managed through a divisional structure that covers all the hospitals within the trust, with some staff rotating between the three sites of Gloucestershire Royal Hospital, Cheltenham General Hospital and Stroud Maternity Hospital; therefore there are significant similarities between the content of the three location reports.

Our key findings were as follows:

Safe

  • Safety was judged as good in critical care and surgery, but in all other areas it required improvement.
  • The emergency department was frequently overcrowded; this was associated with a lack of patient flow, which in turn led to the risk that patients might not be promptly assessed, diagnosed and treated. Patients were not always cared for in the appropriate part of the department, with particular concerns about the safety of patients being cared for in the corridor when the department was so busy that it could not accommodate patients in clinical areas.
  • Staff were aware of how to report incidents and felt encouraged to do so. However, overall the trust was reporting fewer incidents than the national average (6.8 per 100 admissions compared with 9.3 per 100 admissions for the NHS England average in the period from November 2013 to October 2014).
  • The majority to staff stated they received feedback after reporting incidents. In all areas there were examples of learning from incidents.
  • Overall, the hospital was visibly clean; however some areas, such as the room for patients with mental health needs and areas in the medical wards, were found to be dusty, dirty and, or to contain litter. We also found a number of hand gel dispensers that were empty.
  • The number of cases of Clostridium difficile was significantly lower than in previous years, and at 34 cases up to February 2015 was well below the trust’s target of a maximum of 55 for the year ending April 2015. There had been just one case of methicillin-resistant Staphylococcus aureus (MRSA) in the year to date.

  • Throughout the hospital we found medication stored in resuscitation trolleys was not secured to demonstrate it had not been tampered with between checks.

    • In some areas, records were not stored securely.
    • Review of ‘do not attempt cardio-pulmonary resuscitation’ (DNA CPR) forms showed that the forms did not consistently demonstrate or link to a reference of patients’ mental capacity, and this information was not obvious or easily accessible in other records. Explanations for the reason for the decision to withhold resuscitation were not always clear, and records of discussions with patients and their next of kin, or of reasons why decisions to withhold resuscitation were not discussed, were always not documented.
    • The majority of staff had attended safeguarding training in order to keep people safe from abuse. The exception to this was staff in urgent and emergency services, where for level 2 child protection training, particularly for junior doctors, completion rates were low, at 68% compared with the trust’s target of 90%.
    • Staff had access to a range of mandatory training, and attendance was monitored. Records showed that the majority of staff had attended the required mandatory training, and the trust’s target of 90% was exceeded. However, in the unscheduled care division, medical staff were performing less well at accessing such training.
    • Systems were in place to assess and respond to patient risk; these included risk assessments relevant to patients’ needs and early warning scoring systems to determine whether patients were at risk of deteriorating.
    • The trust’s target for completion of venous thromboembolism (VTE) risk assessment had not being met since the first quarter of 2013/14.
    • Nurse staffing levels had been reviewed and assessed, with oversees recruitment having taken place in order to meet the National Institute for Health and Care Excellence (NICE) Safe Staffing Guidance. Some areas, such as the flexible capacity wards, relied heavily on the use of bank and agency staff.
    • Medical staffing was at safe levels in many services. However, there were some exceptions; these included consultants in acute medicine, general and old age medicine and radiology, and junior doctors in medicine and emergency care.
    • The trust had a major incident and business continuity plan in place. The majority of staff were aware of their roles and responsibilities should the plan be activated.

Effective

  • Services were found to be effective in surgery, maternity and gynaecology, children and young people, end of life care and critical care. The latter we judged as outstanding. Improvements were required in urgent and emergency services and medicine.
  • In most services, people’s needs were assessed and care and treatment delivered in line with legislation, standards and evidence-based guidance.
  • Mortality rates were in line with those of other trusts, as measured by the Hospital Standardised Mortality Ratio.
  • Information about patient outcomes was routinely collected and monitored, with the trust participating in a number of national audits so it could benchmark its practice and performance against that of other trusts. In a number of these audits, the trust was performing less well than other trusts, for example the College of Emergency Medicine (CEM) audits, the National Sentinel Stroke Audits, The National Heart Failure Audit, and the Royal College of Physicians National Care of the Dying Audit 2104. Overall in surgery and critical care, the trust was performing better than the England average in most of the national audits it took part in.
  • Patient pain was assessed and well managed; the exception to this was in the emergency department, where not all patients had a pain score recorded and not all patients consistently received prompt pain relief.
  • In the ward areas, we found that patients had access to adequate food and fluids, observing that drinks were left within their reach.
  • Staff had access to training to develop their skills, knowledge and experience to deliver effective care and treatment. The trust’s target for the percentage of staff who had an annual appraisal was 90%, with the actual figure standing at 85%.
  • Multidisciplinary working was evident in all areas we inspected.
  • Overall patients were assessed in line with the Mental Capacity Act 2005 and care and treatment for patients unable to consent was undertaken in line with their best interest. However we did find one example where we were unable to find a documented assessment of a patient's capacity to make decisions despite evidence that this person was confused.
  • The hospital was working towards providing services seven days a week. The pharmacy service was open for limited hours on a Saturday and Sunday. Some on-call cover was provided at weekends by allied health care professionals. The palliative care team was available from 9am to 5pm Monday to Friday, with the specialist palliative care nurses providing an out-of-hours telephone advice service for clinicians.
  • Weekend ward rounds did not take place in some areas such as stroke, gastroenterology or the diabetes and endocrinology wards. In cardiology, a ward round took place on both days of the weekend.
  • Weekend discharges were problematic, with significantly fewer patients being discharged at this time.

Caring

  • Staff were providing kind and compassionate care with dignity and respect. Caring in critical care was outstanding, with all other areas rated as good.
  • In some areas such as the surgical admissions unit and outpatients, at times privacy could be compromised when personal conversations could be overheard and procedures seen.
  • Prior to the inspection we received a number of concerns from patients and relatives about a lack of clear communication; however, during the inspection we found that patients and, when appropriate, those close to them, were involved in decisions about patients’ care and treatment.
  • Patients generally received the support they needed to help them cope emotionally with their care, treatment and condition.
  • Spiritual support was available from within the hospital through the chaplaincy service, which provided a 24-hour on-call service.

Responsive

  • Urgent and emergency care and medicine required improvement; all other services were rated as good.
  • Bed occupancy at Gloucestershire Royal Hospital was constantly over 91%, which was above both the England average of 88% and the 85% level at which it is generally accepted that bed occupancy can start to affect the quality of care provided to patients and the orderly running of the hospital. The hospital had been operating at near 100% occupancy in the months leading up to the inspection.
  • There were issues with the flow of patients into, through and out of the hospital. The emergency department frequently became overcrowded when demand for services exceeded capacity. This was a hospital- and community-wide issue. In December 2014 and January 2015, the trust had declared an internal major incident when the situation became unmanageable.
  • The standard that requires 95% of patients to be discharged, admitted or transferred with four hours of arrival in A&E was consistently not being met. Trust wide performance was 82.86% with Gloucestershire Royal Hospital achieving 80.59%.
  • There were numerous examples of initiatives to reduce inappropriate emergency department attendances, to ensure patients were directed to the appropriate services to prevent admission and to shorten length of stay. Some of these were in their infancy and not yet fully developed to enable an effective and comprehensive service to be provided seven days a week.
  • The average length of stay for patients admitted as elective cases fell to its lowest level in February 2015; however this masked a performance that was better than the national average in surgery and worse than the national average in medicine. For non-elective patients, the average length of stay had risen to 6.7 days, which was above the trust’s target of 5.8 days for the third month in a row.
  • The number of emergency admissions within 30 days of discharge for both elective and emergency patients was above the trust’s target and had been for the last year.

  • The 18-week referral to treatment targets were being met in almost all surgical specialities. Urology and ophthalmology were just behind the 90% target at 85% and 87% respectively. The trust was below (that is worse than) the NHS England average 62-day cancer waiting time target.

  • The number of elective patients cancelled on the day of admission for a non-medical reason had not met the target in over a year, reaching its peak over the three months from December 2014 to February 2015, which matched the time during which the trust had been facing significant increased demand. This was also reflected in the number of patients who were cancelled and not rebooked within 28 days, which saw a significant rise in January 2015.

    • There was an agreement with partners in the local health economy that the daily number of patients who were medically fit for discharge would not be more than 35 a day; this number had reached 74 in February 2015.
    • The two-week wait target for urgent GP referrals for cancer and the 62-day wait from GP referral to treatment were not consistently being met. However, other targets such as the 31 days for surgery and radiotherapy were constantly met, as was the 31-day period from diagnosis to treatment.
    • Systems were in place to identify patients who were living with dementia or who had a learning disability and might need additional support.
    • Patients knew how to make a complaint if they wanted to, and information was available around the hospital outlining how to make a complaint and how it would be dealt with. There were examples of learning from complaints to improve care.

Well led

  • Leadership in critical care was rated as outstanding; surgery, maternity and gynaecology, children and young people, and outpatients were also well-led. Urgent and emergency care, medicine and end of life care all required improvement.
  • Most services had a five-year strategy in place. The exception to this was end of life care. Whilst the team demonstrated understanding of the national policy and priorities, there were no defined work plan priorities for Gloucestershire Royal Hospital for the present and future.
  • Staff were generally aware of the trust’s values of listening, helping, excelling, improving and uniting.
  • The trust was organised into four clinical divisions which operated across all trust sites; each was led by a chief of service, a divisional nursing director and a divisional operations director. This team was supported by a clinical director, a matron and a general manager in each specialty. Staff in all areas stated they felt supported by these lead staff. Of the executive directors, the director of nursing was singled out by many staff as visible and approachable.
  • Generally appropriate governance systems were in place; each specialty had governance meetings, and these were reported to the divisional governance meetings, with significant issues reported on to the trust’s quality governance meetings. Shortcomings were identified in two main areas. Monitoring of mortality and morbidity meetings in medicine was poor. We were informed these meetings took place, but we were not able to view any minutes of these meetings. In end of life care, governance and quality measurement were inconsistent. Whilst governance meetings were held, the minutes lacked details on information relating to actions planned or taken.
  • In the 2014 staff survey, the trust was performing less well than other trusts on staff engagement; however, there had been an improvement from the previous year. Many staff told us about the executive walk-arounds and the top 100 leaders’ information meetings.

We saw several areas of outstanding practice including:

  • Patients living with dementia on Ward 9b were able to take part in an activity group, which had been organised by one of the healthcare assistants. The activity group enabled the patients to become involved in activities and encouraged them to maintain their skills and independence. The group was held weekly, and patients were able to play bingo, watch films, take part in reminiscence, paint, sing and eat lunch together. Activities were tailored to individual preferences, and relatives were encouraged to be involved.

  • The trust had a mobile chemotherapy unit which enabled patients to receive chemotherapy treatment closer to their homes, to prevent frequent travel to hospital.

  • Patient record keeping in critical care was outstanding. All the patients’ records we saw were completed with high levels of detail. The records contained all the essential details to keep patients safe and ensure all staff working with them had the right information to provide safe care and treatment at all times.

  • There was an outstanding holistic and multidisciplinary approach to assessing and planning care in the department of critical care. All the staff involved with the patients worked with one another to ensure the care given to the patient followed an agreed treatment plan and team approach. Each aspect of the care and treatment had the patient at its centre.

  • In critical care, there was an outstanding commitment to education and training by both nurses and trainee doctors. Nurses and trainee doctors followed comprehensive induction programmes that were designed by experienced clinical staff over many years. All the staff we met who discussed their training and development spoke very highly of the programmes on offer and there being no barriers to continuous learning.

  • There was outstanding care for bereavement in critical care. All staff spoke highly of how they were enabled to care for and support patients and relatives at this time. Bereavement care had been created with input from patients, carers, relatives and friends, and staff were particularly proud of the positive impact it had on bereaved people and patients nearing or reaching the end of their life.

  • The outstanding arrangements for governance and performance management in critical care drove continuous improvement and reflected best practice. There was a serious commitment to leadership, governance and driving improvements through audits, reviews, and staff honesty and openness. All staff had a role to play in this area and understood and respected the importance of their work.

  • Mobility in labour was promoted with the Mums Up and Mobile (MUM) programme, which included wireless cardiotocography (CTG) monitoring across the whole of the delivery suite.

Importantly, the trust must:

  • Improve its performance in relation to the time patients spend in the emergency department to ensure that patients are assessed and treated within appropriate timescales.

  • Continue to take steps to ensure there are sufficient numbers of suitably qualified, skilled and experienced consultants and middle grade doctors to provide senior medical presence in the emergency department 24 hours a day, seven days a week, and to reduce reliance on locum medical staff.

  • Continue to reduce ambulance handover delays and take steps to ensure that patients arriving at the emergency department by ambulance do not have to queue in the corridor because there is no capacity to accommodate them in clinical areas.

  • Develop clear protocols with regard to the care of patients queuing in the corridor. This should include risk assessment and the identification of safe levels of staffing and competence of staff deployed to undertake this care.

  • Work with healthcare partners to ensure that patients with mental health needs who attend the emergency department out of hours receive prompt and effective support from appropriately trained mental health practitioners.

  • Take immediate steps to address infection control risks in the ambulatory emergency care unit.

  • Ensure that systems to safeguard children from abuse are strengthened by ensuring that children’s safeguarding assessments are consistently carried out, and safeguarding referral rates are audited to ensure they are appropriate.

  • Ensure that senior medical staff in the emergency department are trained in level 3 safeguarding.

  • Ensure that patients in the emergency department have an assessment of their pain and prompt pain relief administered when necessary.

  • Take steps to strengthen the audit process in the emergency department to provide assurance that best (evidence-based) practice is consistently followed and actions continually improve patient outcomes.

  • Ensure minutes are kept of mortality and morbidity meetings in medicine so that care is assessed and monitored appropriately, lessons learnt and actions taken and recorded.

  • Ensure that patients’ records across the hospital are stored securely to prevent unauthorised access.

  • Ensure that the premises for the medical day unit are suitable to protect patients’ privacy, dignity and safety.

  • Ensure an effective system is in place in the medical wards to detect and control the spread of healthcare-associated infection.

  • Ensure patients’ mental capacity is clearly documented in relation to ‘do not attempt cardio-pulmonary resuscitation’ (DNA CPR) and ‘unwell/potentially deteriorating patient plan’ (UP) forms. Improvements in record keeping must include documented explanations of the reasoning behind decisions to withhold resuscitation, and documented discussions with patients and their next of kin, or reasons why decisions to withhold resuscitation were not discussed.

  • Ensure that where emergency equipment in the form of resuscitation trolleys is not available, the decision to not supply is based on a thorough risk assessment. Where emergency equipment is available, this should be ready to use at all times.

  • Review communication methods within maternity services to ensure sensitive and confidential information is appropriately stored and handled whilst being available to all appropriate staff providing care for the patient concerned.

  • Ensure that systems are in place to ensure that medication available in departments is in date and therefore safe to use.

In addition the trust should:

  • Review how staff perceive the feedback they get from incident reporting and the level of detail received.

  • Ensure that patients, including children, are adequately monitored in the emergency department waiting room to ensure that seriously unwell, anxious or deteriorating patients are identified and seen promptly.

  • Take steps to improve the experience for patients and visitors in the emergency department waiting room. This should include the provision of drinking water, a TV, and appropriate reading material and information about waiting times.

  • Review the emergency department nursing staff mix and training to ensure adequate numbers of staff are trained to identify, care for and treat seriously ill children.

  • Continue to improve hospital-wide ownership of the emergency department four-hour target, to ensure that delays in admission are minimised.

  • Reduce the number of patients who have their operation cancelled on the day of surgery, and reduce the number of patients not rebooked within 28 days.

  • Ensure all staff in surgery services are able to demonstrate and understanding of the requirements of the Mental Capacity Act and Deprivation of Liberty Safeguards, so patients are not put at unnecessary risk of staff not acting legally in their best interests. Ensure there is appropriate documentation in place to support decisions.

  • Ensure that the ambulatory emergency care unit is sited in an appropriately equipped area that is conducive to ensuring patients’ comfort and dignity.

  • Consider displaying feedback from patients and relatives for each individual medical ward.

  • Consider a system to identify when patient equipment has been cleaned.

  • Ensure all areas are clean and free from litter.

  • Store all medicines in critical care in a way that meets requirements for their security.

  • For safety of the medicines and equipment inside, ensure resuscitation trolleys are secured in such a way so there is clear evidence if they have been opened between checks.

  • Capture and report safety thermometer data in the department of critical care alongside the other data on patient harm that the department collects.

  • Ensure all items are within their expiry date.

  • Maintain continuity of care for patients on the day surgical unit to ensure they have their needs met 24 hours a day, seven days a week.

  • Review the medical and surgical cover at weekends for the day surgery unit to make sure patients are reviewed and discharges not held up.

  • Ensure patients who are admitted to the surgical day surgery unit can have their needs met by the staff team.

  • Reduce the number of times patients are moved between wards, for continuity of care.

  • Review the staffing levels of physiotherapists against the requirements of the Faculty of Intensive Care Medicine Core Standards.

  • Ensure the specialist palliative care team can be sustained and are able to remain responsive to the evidenced increased demands of complex referrals, provide a face-to-face seven-day service, provide ongoing staff training in line with national policy, and make improvements to inconsistent governance, risk management and quality measures.

  • Ensure that a strategy for end of life care is developed.

  • Ensure all patients who are referred by their GP with suspected cancer are seen with two weeks of referral, and treatment is started within 62 days of referral.

  • Ensure the cleaning arrangements for all outpatient areas are appropriate to maintain a high standard at all times.

  • Ensure that where medication is required to be stored at refrigeration temperatures, systems are in place to monitor the correct temperature.

  • Ensure that systems are in place in outpatients to identify in a timely manner and replace medication that is approaching its expiry date, to prevent potential harm to patients.

  • Ensure patients’ privacy and dignity is consistently respected in the outpatient department and medical unit.

  • Ensure patients in outpatients have access to information on the trust’s complaints procedure, and that this is readily available in all areas.

  • Ensure staffing levels and the skill mix of staff in the diagnostic and imaging teams meet the needs of patients at all times and support staff to deliver a quality service.

  • Review, in the maternity services, the midwifery and support staffing to ensure there are sufficient staff to meet patients’ needs at all times in all areas.

  • Ensure that in maternity services, both service risk registers detail actions underway to mitigate risks.

  • Review cleaning schedules in maternity services and devise systems to ensure staff know when equipment has been cleaned and is ready for use.

  • Within gynaecology, review recalibration schedules for weighing scales.

  • Within maternity services, review the provision of oxygen and air on resuscitaires to ensure that the correct gases are administered during resuscitation, in line with the Resuscitation Council guidelines.

  • Review the location of the maternity services’ registrar clinic and early pregnancy assessment clinic (at weekends) to ensure facilities are appropriate to provide care, assessment and treatment.

  • Review the processes to ensure early screening (pre 10 weeks’ gestation) can occur where the need for such screening is indicated.

  • Within maternity services, work with the wider organisation to ensure overall patient flow is effective to prevent the need for cancellation of gynaecology patients because of the need to accommodate other patients on Ward 2a.

  • Review the timeliness of access to patient information in alternative languages.

  • Ensure staff in all areas of maternity services are aware of the procedures to follow in the event of early discharge ahead of the completion of all bereavement processes.

  • Ensure all patients’ referral-to-treatment times do not exceed national targets, and that services are delivered in a way that focuses on patients’ holistic needs and does not mean patients experience long delays in receiving their first outpatient appointment.

Professor Sir Mike Richards, Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 19 June 2015

Effective

Requires improvement

Updated 19 June 2015

Caring

Good

Updated 19 June 2015

Responsive

Requires improvement

Updated 19 June 2015

Well-led

Requires improvement

Updated 19 June 2015

Checks on specific services

Maternity and gynaecology

Updated 5 July 2017

We did not rate this service as we did not inspect all domains. However, we found:

  • All areas had access to emergency resuscitation trolleys. However, in some areas, a systematic check of the trolleys was not documented as having being carried out on a daily basis. There were no up to date Resuscitation Council (UK) guidelines available on the resuscitation trolleys. Intravenous fluids on the emergency resuscitation trolleys were not stored securely to ensure they were tamper proof. This meant staff could not be assured the right equipment and guidance would be available in the case of an emergency.
  • Not all drug storage fridge temperatures were documented daily. There was no process in place if a temperature fell outside of acceptable limits. This meant staff could not be assured medicines requiring refrigeration were being stored at the required temperatures.
  • There were a number of out of date patient group directives (PGD’s) in use in maternity services. The lists of medicines that were subject to PGD’s had no doses or route of administration detailed on them. We drew this to the attention of senior staff and the PGD’s were removed from use.
  • Community midwives could not always print out clinical notes from the electronic system to go into women’s handheld notes. They also reported poor mobile phone coverage which meant there was sometimes a delay in getting messages. This could have an impact on a woman who was trying to get some help or advice from a midwife.
  • An electronic patient record system had been introduced trust wide in December 2016. There were some ongoing issues with allocation of baby NHS numbers and records migrating to the new system. This meant that babies may miss out on vital tests following birth. Midwives had devised solutions to ensure each baby had an NHS number.
  • Senior House Officers (SHO) did not attend skills drills training when they started at the trust. Those that spoke to us said whilst they did not cover the delivery suite they did carry an emergency bleep and if they arrived in the delivery suite first they often felt out of their depth.
  • There were often long waiting times in the triage area. Whilst systems were being put in place to increase medical and midwifery staffing, women were not seen within 15 minutes of attending the unit. This could mean that urgent issues may be missed.
  • Consultant presence, on labour suite, was below the recommendations of the Royal College of Obstetricians and Gynaecologists (RCOG) Safer Childbirth (2007) guidance.

  • Speciality trainee doctors (ST3 and ST4) and some consultants felt that a senior house officer equivalent was needed at night as sometimes no other medical staff to assist with emergency caesarean sections were available. This also meant other patients, across maternity and gynaecology services, who needed to see a doctor sometimes had to wait for long periods of time.
  • The morning medical handover was informal and there was no input from the co-ordinating midwife about the women in labour at the time of the meeting. The registrar who had been on duty overnight presented the cases but said they were often tired and did not always have the full up to date details of the women. This may mean that the most up to date information is not being given to the next staff coming on duty.

However:

  • Staff understood their responsibilities to raise concerns and report incidents using the electronic reporting system. There was a culture of shared learning from incidents.
  • Staff spoke confidently about the duty of candour and gave examples of where it had been applied. Relevant staff had received training.
  • All areas we visited were visibly clean and tidy. There were antibacterial hand sanitizers at the entrances to each unit/ward. Staff were seen adhering to the trusts infection control policies including ‘bare below the elbows”. This meant people visiting the maternity services were protected from the spread of infection.
  • All rooms on the delivery suite, including the triage area had wireless cardiotochograph (CTG) machines for monitoring the foetal heart. The CTG machines were linked to a central monitor point, which allowed the co-ordinating midwife to review traces. The wireless aspect meant women could still be monitored whilst in a birthing pool.
  • Doors into all wards/units were locked, with a buzzer entry system and CCTV. Although reception areas were not manned 24 hours per day; when there was no receptionist other staff on duty took on the role. A baby security tagging system was in place on the maternity unit.
  • There were systems in place for recognising and reporting safeguarding concerns. Staff were confident to raise any matters of concern and escalate them as appropriate.
  • A ‘vulnerable women’s team’ had been developed that included a full time perinatal mental health midwife, substance misuse and teenage pregnancy midwife and the lead safeguarding midwife. The team were able to offer an enhanced service to those women identified as being at risk. The team also offered advice and support to midwives who had concerns.
  • Staff said there was good access to mandatory training. Mandatory training for maternity services included a PROMPT (Practical Obstetric Multi-Professional Training) skills drills training day and a one-day maternity update for staff working within the maternity unit.
  • The maternity services offered Birth Choices Clinic for women identified as being high risk but who requested midwife-led care. They were seen by a supervisor of midwives and a complex care plan devised in agreement with the woman and in discussion with an obstetrician.
  • The service had a commitment to managing women’s peri-natal mental health issues and were trying to establish a team to include a consultant psychiatrist.
  • The development of a training package for midwives to enable them to administer flu vaccinations to at risk women had meant that a high number of women who would otherwise have not had the flu vaccine had received it.
  • The gynaecology ward had been relocated, in December 2016, to a ward with less beds (20 beds to 13 beds) to reduce the incidence of outlying patients (that is patients from medical or surgical wards) which sometimes meant elective gynaecology surgery had to be cancelled. The ward sister said the number of outliers had reduced significantly and as a result there were less elective gynaecology procedures being cancelled.
  • The clinical scorecard between April 2016 and November 2016 showed that staff were providing one-to-one care in labour 98% of the time.
  • A telephone triage system staffed by midwives was located within an ambulance service hub. Midwives directed women to the most appropriate place for their care. The system had reduced the volume of calls directly to the triage area.
  • There was 24-hour consultant on-call cover. The delivery suite had access to anaesthetists 24 hours a day, seven days a week. Doctors we spoke with said that consultants always came in at night if they were asked to.

Medical care

Requires improvement

Updated 19 June 2015

Medical care (including older people’s care)

Requires improvement

Updated 5 July 2017

We rated this service as requires improvement because:

  • Nursing staffing levels were below establishment and wards relied on bank and agency to cover shifts every day.
  • Theservice did not assess or record the acuity of patients on each shift and on each ward to ensure safe staffing levels.
  • The medical service did not consistently review the effectiveness of care and treatment through national audits.
  • The service had a strategy to understand and improve performance on hospital-based mortality indicators. While most specialities held mortality and morbidity (M&M) meetings monthly or quarterly we were concerned that not all specialties held meetings regularly and how effectively learning was shared.
  • There were some concerns about the safe transfer of patients receiving intravous therapy during ambulance transfers to other hospitals.
  • Staff did not always follow infection control procedures when entering wards and ensuring the cleanliness of equipment such as commodes.
  • Staff did not always comply with legislation regarding the Control of Substances Hazardous to Health (COSHH).
  • Daily checking of equipment such as resuscitation equipment was not carried out in line with the trust’s policy in all areas.
  • Staff did not monitor fridge temperatures consistently or take actions where these fell out of normal range, which meant medicines were not always stored correctly.
  • Staff were unsure of when to dispose of some medicines in line with manufacturer’s recommendations.
  • Records were not stored safely to ensure patient’s confidentiality was maintained.
  • Staff did not always assess risks to patients or follow up identified risks with mitigating care interventions.
  • The medical service did not consistently review the effectiveness of care and treatment through national audits.
  • Staff did not always put actions in place when patients were at risk of malnutrition.
  • Compliance with annual appraisals were below the trust’s target.
  • There were delays in discharging patients; although this was largely caused by factors outside of the medical services remit.
  • Information was not always accessible to staff including information about care and treatment pathways.
  • The delivery of cardiology services did not meet the needs of the local population.
  • There were delays to discharges, which meant patient flow through the hospital was compromised.
  • The environment did not meet the needs of patients with dementia.
  • The service was not always compliant with the accessible information standards and information leaflets were not readily available for patients for whom English was not their first language.
  • Risks registered on the risk register were not always aligned with risks in the service
  • There was a limited approach to obtaining the views of patients and their relatives

However:

  • Staff understood their responsibility to report incidents and there were processes in place to review incidents and ensure learning was shared across the trust.
  • The endoscopy unit had safe processes in place to ensure staff decontaminated and sterilised equipment in line with best practice.
  • Staff were aware of their responsibilities for identifying and reporting safeguarding issues.
  • There were safe processes in place to review patients and ensure care and treatment plans were followed up.
  • Patients were positive about the way they were treated and cared for in the medical wards. Where staff were observed treating patients with kindness, dignity, respect and compassion.
  • Patients praised staff for providing further information when asked.
  • There was a competence training and assessment framework in place to ensure nurses were competent to carry out extended skills and nursing staff were supported with revalidation processes.
  • There was an effective framework for ‘board round’ and ward rounds and included input from staff from the multidisciplinary healthcare team.
  • Processes were in place to ensure consultants reviewed patients seven days a week.
  • Staff were aware of the mental capacity assessment and applications for deprivation of liberty safeguards.
  • The trust’s referral to treatment time (RTT) for admitted pathways for medical services was better than the England overall performance between November 2015 and October 2016.
  • The trust had a clear vision and some specialities within the medical division had a vision to expand and improve services.
  • Staff felt supported by managers and senior management felt assured by the new executive team.

Urgent and emergency services (A&E)

Requires improvement

Updated 5 July 2017

We have rated this service as requires improvement overall because:

  • We had concerns about patient safety, particularly when the department was crowded, which was a regular and frequent occurrence. Capacity was compromised because ED attendances were increasing, both in numbers and in terms of patient acuity. Lack of patient flow within the hospital and in the wider community created a bottle neck in the ED, creating pressures in terms of space and staff capacity. This in turn increased the risk that patients may not be promptly assessed, diagnosed and treated.
  • Crowding was compounded by a significant shortage of staff. There were particular concerns with regard to the lack of senior decision makers at night. Consultants were regularly working additional hours to support more junior colleagues at night. Support staffing was also under-resourced, putting more pressure on clinical staff.
  • The trust was consistently failing to meet the national standard which requires that 95% of patients are discharged, admitted or transferred within four hours of arrival at the emergency department. A significant number of four hour breaches were attributed to a shortage of inpatient beds. The trust was not meeting the standard which required that patients are reviewed by a doctor within one hour.
  • Patients were not consistently assessed promptly on arrival and in some cases a face to face assessment did not take place for some time. Ongoing monitoring of patients was not undertaken with the required frequency. This meant there was a risk that seriously unwell or deteriorating patients may not be identified and managed promptly.
  • Patients’ records were not consistently completed to provide an accurate record of care and treatment provided. Record keeping was notably worse when the department was crowded. Records did not assure us that patients regularly had their pain or their skin integrity assessed or had been offered food and drink.
  • Patients waited too long in the emergency department after the decision had been made to admit them to an inpatient bed. Patients regularly queued in the corridors in the emergency department and their relatives sometimes had to stand because there was insufficient seating. Despite the efforts of staff, patients’ comfort and dignity could not be maintained in the corridor.
  • Patients who attended the emergency department with mental health needs did not always access prompt assessment and support from mental health practitioners, particularly if they attended out of hours. Although there was a designated mental health assessment room, it did not comply with safety standards and was not a welcoming space.
  • Pressures faced by staff in the emergency department in relation to crowding were well understood and articulated by the management team. However, it did not appear that the risks relating to staff wellbeing, resilience and sustainability had been widely shared or escalated within the organisation and they were not included on the department’s risk register.
  • Safety concerns which we identified at our last inspection had not been addressed, despite the introduction of new processes. Poor patient flow remained the major barrier to progress. The emergency department’s management team did not feel there was a culture of collective responsibility within the trust in relation to patient flow. There was frustration expressed that the emergency department bore a disproportionate level of risk, while the responsibility for the exit block sat with others. The emergency department was unable to influence the cultural shift which was required to address this significant barrier to improving patient flow and capacity.

However:

  • The emergency department was taking steps to mitigate the risks associated with crowding. Hourly board rounds conducted by senior clinicians provided an overview of activity and provided an opportunity to identify and communicate safety concerns to the site and trust management teams.
  • A patient safety checklist had been introduced, which provided a series of time-sequenced prompts for staff to undertake risk assessments, observations, tests and treatments. However, the use of this documentation was yet to be embedded in practice and was not consistently completed.
  • There were few serious incidents reported in urgent and emergency care. We saw good evidence that when incidents occurred, lessons were learned and improvements were made. There was openness and transparency about safety. Staff were familiar with their responsibilities under the Duty of Candour regulation.
  • There were effective processes in place for the identification and management of adults and children at risk of abuse and staff were familiar with these.
  • There was a range of recognised treatment protocols and care pathways. Compliance with pathways and standards was monitored through participation in national audits. Performance in national audits was mostly in line with other trusts nationally. There was evidence that audit was used to improve performance, for example in the treatment of sepsis.
  • Nursing and medical staff received regular teaching and clinical supervision. Staff were encouraged and supported to develop areas of interest in order to develop professionally and progress in their careers.
  • Care was delivered in a coordinated way with support from specialist teams and services, such as the stroke team. There was a range of admission avoidance initiatives in place to improve patient flow. These included the discharge assessment team, the older people’s assessment and liaison service, the mental health liaison service and the alcohol liaison service, who all worked closely and collaboratively with the emergency department. The clinical commissioning group had also commissioned a pilot whereby GPs worked in the ED on weekdays and appropriate patients were streamed to see either a GP or an advance nurse practitioner.
  • The emergency department had recently developed a team known as the Gloucestershire elderly emergency care (GEEC), championed by an ED consultant. The aim was to raise awareness of the issues faced by frail elderly patients in the emergency department and to identify areas where the experience of this patient group could be improved.
  • Multi-agency management plans had been developed for patients with mental health needs who were frequent attenders in the ED. These enabled staff to better support patients and had resulted in a reduction of both ED attendances and admissions to hospital.
  • Complaints were listened to and acted upon. There was evidence that changes and improvements had been made in response to complaints.
  • All of the patients we spoke with during our inspection commented very positively about the care they received from staff. This was consistent with the results of patient satisfaction surveys, which were mostly positive.
  • Patients were treated with compassion and kindness. We saw staff providing reassurance when patients were anxious or confused.
  • Patients were treated with courtesy, dignity and respect. We observed staff greeting patients and their relatives and introducing themselves by name and role.
  • Patients and their families were involved as partners in their care. We heard doctors and nurses explaining care and treatment in a sensitive and unhurried manner.
  • There was a strong, cohesive and well informed management team who were highly visible and respected.
  • There was an effective governance framework. Information was regularly monitored to provide a holistic understanding of performance, which included safety, quality and patient experience. Risks were understood, regularly discussed and actions taken to mitigate them.
  • The emergency department had developed an improvement plan with clear milestones and accountability for actions.
  • Staff morale was mainly positive, although this had been somewhat overshadowed by crowding and the pressures this placed on staff. Staff nevertheless felt valued and supported.
  • There were cooperative and supportive relationships among staff. We observed exceptional teamwork, particularly when the department was under pressure.
  • There was a strong focus on learning and improvement. Clinical audit was well managed and used to drive improvement. Mistakes were openly discussed and learning acted upon. Staff at all levels were encouraged to play their part in improving patient experience.

Surgery

Updated 5 July 2017

We did not rate this service as we did not inspect all domains. However, we found:

  • Since our inspection in March 2015, the number of surgical site infection rates had increased for replacement hips, knees, and spinal surgery.
  • There had been two never events reported in surgery since our last inspection. These had been investigated and actions taken to prevent these happening again.
  • Storage for patients’ notes on some wards and units was not secure, which meant unauthorised people could have had access to these confidential records.
  • Mandatory training for all staff was not meeting the trust’s target.
  • The surgical division was not meeting the trust’s target for staff appraisals.
  • Due to pressure for beds and the demand for services, some patients had to use facilities and premises that were not always appropriate for inpatients and support services were not always set up and staff did not know how to set them up.
  • Elective operations were being cancelled due to the pressure on the beds within the trust, and surgical wards were being used to accommodate medical patients.
  • The trust had introduced a new computer system prior to our inspection that was causing some issues for staff resulting in 'work around' processes to prevent any risks to patients.

However:

  • The service encouraged openness and transparency from staff with incident reporting, and incidents were viewed as a learning opportunity. Staff felt confident in raising concerns and reporting incidents.
  • The trust had been identified as a ‘mortality outlier’ in to relation Reduction of fracture of bone (Upper/Lower limb)’ procedures, which included fractured hip. However, the actions they had implemented had made improvements and these were ongoing at the time of our inspection. For example, in the 2016 hip fracture audit which had shown an improvement on 2015 audit
  • Training in safeguarding of adults and children had met the trust target for completion.

Intensive/critical care

Outstanding

Updated 19 June 2015

The effectiveness, caring and leadership of the service were outstanding, and safety and responsiveness were good. Treatment, care and rehabilitation by all staff were delivered in accordance with best practice and recognised national guidelines. There was a holistic and multidisciplinary approach to assessing and planning care and treatment for patients. Patients were at the centre of the service and the overarching priority for staff. Innovation, high performance and the highest quality care were encouraged and acknowledged. All staff were engaged in monitoring and improving outcomes for patients. They achieved consistently good results for patients who were critically ill and with complex problems and multiple needs.

Patients were truly respected and valued as individuals. Feedback from people who had used the service, including patients and their families, had been exceptionally positive. Staff went above and beyond their usual duties to ensure that patients experienced compassionate care and that care promoted dignity. People’s cultural, religious, social and personal needs were respected. Innovative caring for patients, such as the development of patient diaries, was encouraged and valued.

The leadership, governance and culture were used to drive and improve the delivery of high quality person-centred care. All the senior staff were committed to their patients, their staff and their unit, with an inspiring shared purpose. There was strong evidence and data to base decisions upon and drive the service forwards from a clear, approved and accountable programme of audits. There was a high level of staff satisfaction, with staff saying they were proud of the unit as a place in which to work. They spoke highly of the culture and consistently high levels of constructive engagement. Innovation and improvement was celebrated and encouraged, with a proactive approach to achieving best practice and sustainable models of care.

There was a strong track record on safety, and lessons were learned and improvements made when things went wrong. This was supported by staff working in an open and honest culture and by a desire to get things right. Staff responded appropriately to changes in risks to patients. There was high quality equipment and a safe environment. The unit was clean and well organised. Staff adhered to infection prevention and control policies and protocols. There were good levels of nursing and medical staff meeting the Core Standards for Intensive Care Units to keep patients safe. There was a daily presence of experienced consultant intensivists and doctors, and rarely any agency nursing staff or locum cover used. Patients’ records were excellent, clear, legible and contemporaneous, although their security needed to be improved.

Some improvement was needed to ensure stocks of medicines and other consumables were stored safely, were in date, and details were recorded accurately. The patient harm data was low, but the internal and external recording and display of some information could be improved.

The critical care service responded well to patients’ needs. There were bed pressures in the rest of Gloucestershire Royal Hospital that sometimes meant patients were delayed on discharge from the unit, but the number of incidences was only just above the NHS national average for similar units. Some patients were discharged onto wards at night, when this was recognised as less than optimal for patient wellbeing, but the rate was the same as the NHS national average. There was a very low rate of elective surgical operations being cancelled because a critical care bed was not available.

The facilities in critical care were excellent for patients, visitors and staff, and met all the modern critical care building standards. The trust had responded to the need to improve patient flow by opening a new surgical high dependency unit with four new beds (and expansion capability to six beds) in January 2015.

Patients were treated as individuals and there were strong link nurse roles for all aspects of patient need, including learning disabilities, dementia and mental health. There were no barriers to people who wanted to complain. There were, however, few complaints made to the department. Those that had been made were fully investigated and responded to with compassion and in a timely way. Improvements and learning were evident from any complaints or incidents.

Services for children & young people

Updated 5 July 2017

We did not rate this service as we did not inspect all domains. However, we found:

  • There was an open reporting culture by staff who worked in the children’s services. This helped to maintain the safety of treatment and care for babies, children and young people.

  • There was evidence to show incidents, concerns or trends were investigated for learning opportunities and actions taken to improve practice.
  • Staff understood their roles and responsibilities to safeguard children from potential risks or abuse and received supervision on a regular basis. The trust’s safeguarding teams worked with community and social care colleagues to identify and support children who may be at risk.
  • Systems for staff shift handovers promoted the safety of children. Staff were fully included in processes and encouraged to contribute.
  • Records showed electrical and mechanical equipment was regularly maintained to ensure it was safe to use and review dates were clearly indicated.
  • Risk assessments were used with all children to identify the level of care they needed. These were audited regularly to check they had been completed correctly and concerns had been escalated for further advice where necessary.
  • Staffing levels were regularly reviewed and planned to follow national guidelines and standards. However, staffing levels had been challenged with unexpected staff absences. Managers were taking steps to fill gaps in the short term, recruit staff on a permanent basis and maintain staffing levels.

However:

  • Compliance with audit processes for infection prevention and control was variable across the children’s services and had not been consistently completed.
  • Routine stock checks of some medicines were not always completed according to the trust protocol.

End of life care

Good

Updated 5 July 2017

We rated this service as Good because:

  • End of life care provided at Gloucestershire Royal Hospital was safe, effective caring, responsive and well led because:
  • The processes in place to keep people safe for end of life care were good. Staff in the end of life care team and other areas understood their responsibilities to raise concerns, record safety incidents and report them. Lessons were learned and improvements were made when things went wrong.
  • Patient’s records demonstrated that nutrition and hydration needs were assessed and appropriate actions were documented as followed in patients’ individual care plans.
  • Records documented discussions with relatives around what to expect with the dying process.
  • Risks to patient’s receiving care at end of life were assessed by ward staff with appropriate assessments recorded in medical records for example the prevention and management of pressure ulcers and falls.
  • Staff we spoke with on the wards understood that end of life care could cover an extended period for example in the last year of life and also applied to patients with non-cancer diagnoses such as dementia. Staff, teams and services worked together to deliver effective care and treatment.
  • Staff we observed on wards and in the community delivering end of life care to patients were compliant with key trust policies such as infection control.
  • Arrangements in place for managing medicines kept patients safe. Medicines to relieve pain and other symptoms were available at all times. Wards had adequate supplies of syringe drivers (devices for delivering medicines continuously under the skin) and the medicines to be used with them.
  • There were reliable systems, processes and practices in place to keep patients safe and safeguarded from abuse.
  • The staffing levels and skill mix of the nurse and medical personnel in the specialist palliative care team were planned and reviewed and supported safe practice. We saw evidence of a yearly education programme of end of life care for medical, nursing and allied health professionals. This included: resuscitation, syringe driver training, quarterly end of life study days and symptom management.

  • The specialist palliative care team responded promptly to referrals, usually within one working day.

  • Patients were treated with kindness, dignity, respect and compassion. Staff took the time to interact with people who received end of life care and those close to them in a respectful and considerate manner.
  • We saw many written compliments about how caring staff were in the inpatient and community specialist palliative care team. We saw that patients’ and those people close to them, were involved as partners in their care.

  • The specialist palliative care team and wards staff understood the impact a patients’ care, treatment or condition had on their wellbeing and on those people close to them.

  • Emotional support for patients and relatives was available through the in-patient and community specialist palliative care team, the chaplaincy team and bereavement services. Staff had access to support through their own teams when needed.

  • Services were delivered and additional services planned in order to effectively meet patient’s needs. Plans and actions included audit to inform future planning so that the end of life team could inform better decision making with patients they cared for
  • The bereavement office was one of two sites in the country involved in a pilot project to improve death certification which was more supportive to bereaved relatives and provided better oversight of causes of death.
  • There was a clear vision and strategy to deliver care at end of life. The governance framework for end of life care ensured that responsibilities were clear and that quality, performance and risks were understood and managed.
  • Leadership encouraged openness and transparency and promoted good quality care. There were leads on the wards who supported the development and delivery of high quality end of life care.
  • Services within specialist palliative and end of life care had been continuously improved and sustainability supported since the last inspection March 2015.

However:

  • Documenting ‘Do Not Attempt Cardio-Pulmonary Resuscitation’ (DNACPR) decisions had improved since the last inspection however concerns regarding DNACPR remained. For example not all DNACPR having relevant clinical information and not all patients or those close to them being recorded as involved in discussions about resuscitation. These concerns were not identified as a risk and did not feature on a risk register
  • There were no centrally held training records for syringe driver training or competency for ward staff.
  • There was not a full understanding of performance for all aspects of end of life care. For example the percentage of patients dying in their preferred location and the percentage of patients discharged within 24 hours were not known for all wards or hospital sites.
  • There was no risk register specific to end of life care for the trust so oversight of all end of life risk was not easy.
  • When we reviewed maintenance records some provided were out of date. The trust told us they were clear that equipment listed was not in use. We saw email communication from directors supporting this.
  • There was not a seven day face to face service provided by the in-patient and community end of life care team. The trust provided a face to face service 9-5 Monday to Friday. Out-of-hours there was a telephone advice line available 24 hours, 7 days a week for health care professionals to access.
  • Some of the ‘white rose’ symbols used to locate the mortuary at the hospital were not easy to follow. Signs were not always at eye level for someone walking or in a wheelchair and there were long gaps in signage that led to confusion. Mortuary and bereavement officers told us relatives had commented they were useful. Some relatives had reported they appreciated these signs. However bereavement office staff accompanied relatives when they knew people were attending the mortuary.

Outpatients

Updated 5 July 2017

We did not rate this service as we did not inspect all domains. However, we found:

  • The service did not have sufficient arrangements to keep clinical and patient areas clean. There was no cleaning carried out over the weekend in diagnostic imaging, and some outpatient treatment rooms and waiting areas were visibly dirty.
  • There was not a reliable system to track the number of temporary notes being used since the implementation of a new computer system, and staff were finding it difficult to trace patient notes.
  • There were not sufficient arrangements to ensure staff had access to or knew where to access emergency equipment. Some staff were unsure of their responsibilities in a resuscitation situation, and staff in ophthalmology did not know where to locate their nearest defibrillator.
  • Patients were not protected from avoidable harm in the therapies department as cleaning chemicals were not stored securely.
  • The hospital was not meeting the 62 day waiting list target for cancer patients.
  • Patients were experiencing delays in diagnosis and treatment because the diagnostic imaging department had a reporting backlog of 19,500 films, and was not meeting its five day reporting target for accident and emergency x-rays.
  • A significant typing backlog was causing delays in sending out patient letters impacting on patient safety, diagnosis and ongoing treatment.
  • Implementation of new IT systems had impacted on waiting lists as some specialties could not see their live waiting lists.
  • The trust was not meeting referral to treatment target in all specialities, and patients were waiting longer for to access care and treatment.

However;

  • Incident reporting had improved and in one case the trauma and orthopaedic department to take steps to reduce pressure ulcers. Staff confirmed they now received feedback from incidents they reported.
  • The diagnostic imaging department conducted investigations and had raised safety alerts with an equipment manufacturer which had resulted in changes to practice.
  • Cleaning and infection control procedures had improved in ophthalmology since the last inspection, and there were good decontamination processes in other outpatient departments for equipment that was re-useable.
  • Diagnostic imaging were negotiating one cost service and maintenance contracts for scanners and equipment.
  • Patient were able to access services when they needed to and rapid access assessment clinics were provided in some specialities, and some clinics were performing airway assessments via skype.
  • The hospital had introduced a new waiting list validation process to discharge patients’ ongoing follow up care to community based services such as GPs.
  • A project placing therapists on wards had helped increase patient discharges, and radiographers attended ward briefings to identify inpatients waiting for scans.