- NHS hospital
Gloucestershire Royal Hospital
Assessment report published 27 August 2026
Contents
Ratings - Maternity
Our view of the service
Date of assessment: 8, 9 ,10, 16 & 17 September 2025
We conducted a comprehensive on-site inspection of maternity services provided by Gloucestershire Hospitals NHS Foundation Trust. We visited Gloucestershire Royal Hospital and some of their community midwifery services. At our last focused inspection in March 2024, we looked at elements of safe and well-led, maternity services were rated inadequate for the second time. We issued 8 conditions on their registration to improve the safety of women using maternity services.
At this assessment we assessed all quality statements in the safe, effective, responsive, caring and well-led key questions. We found improvements had been made to maternity care.
We found 1 breach of regulation in relation to safe care and treatment.
We found maternity services had improved from inadequate to requires improvement.
Safe:
Incident reporting and harm assessments were not always completed promptly. Delays in care occurred for some women, and visibility of some care areas was limited. Safeguarding training compliance for medical staff was below the trust target, increasing risks to women and babies. Medicines safety and governance arrangements were not sufficiently supported, limiting effective oversight and safe medicines management
Effective:
Women’s needs were assessed and reviewed. Communication needs and individual personal health requirements were met. Care followed current evidence and good practice. Women had sufficient food and drink, and staff worked with partner agencies to ensure smooth transitions and positive outcomes. Health was monitored to support wellbeing, and staff ensured people understood their care to give informed consent.
Caring:
Women were mostly treated with kindness and compassion. Staff respected privacy and dignity, supported individual preferences, and ensured choice in care. Staff mostly responded promptly to needs. The service generally supported staff wellbeing.
Responsive:
Women were involved in decisions about their care and received clear, accessible information. They knew how to provide feedback and were confident it was acted upon. Care was easy to access, non-discriminatory, and delivered fairly. The service worked to reduce health inequalities through training and feedback, and people understood their options, including the choice to decline care.
Well led:
The service did not have a current strategy to provide a clear direction for future development and improvement. Senior leadership visibility and approachability were not consistently evident to all staff. Some staff did not feel able to speak up or felt they were not treated equitably, creating a risk that concerns affecting quality and safety would not be identified or addressed. While leaders engaged with the local community and supported improvement initiatives, sustainable change had not been embedded at pace, increasing the risk that improvements would not be consistently maintained.
Gloucestershire Hospitals NHS Foundation Trust provides consultant led maternity care based at Gloucestershire Royal Hospital which also provides a midwifery-led birthing unit, labour ward, antenatal and postnatal care. Community services for maternity are provided in and around Gloucestershire. A standalone midwife led birthing unit is also based in Stroud. The Cheltenham midwife led unit remained closed at the time of this assessment.
The number of births recorded from April 2023 to March 2024 for this trust was 5,680
People's experience of this service
Although women and their families consistently reported positive experiences and felt well supported by staff, our assessment identified areas where their care did not consistently meet expected standards.
Most women and families provided positive feedback about staff during our site visits and felt involved in decisions about their care. However, some women reported delays of up to 7 hours in triage and a lack of staff contact while waiting to be assessed. Senior leaders were aware of these concerns and had implemented a triage improvement plan, with ongoing monitoring of performance against the 15-minute initial assessment target.
Women consistently praised staff for their support and dedication. However, some feedback indicated staffing pressures and ward capacity challenges could impact the delivery of care.
Most feedback about staff was positive; however, some women reported variable experiences of support and communication. Concerns included delays in receiving updates, unmet expectations around follow-up contact, and occasions where women felt their concerns were not fully acknowledged. Women were positive about their care overall, although some highlighted the need for clearer and more consistent communication, particularly regarding procedures, recovery and feeding support.
Feedback on the CQC Maternity Survey 2024 was mostly positive. Women were eligible for the survey if they had a live birth under the care of a participating trust in February (and in some cases, January) 2024 and were aged 16 years or over at the time of giving birth.
In comparison with other trusts, Gloucestershire scored about the same for 47 questions and better than expected for the remaining 10 questions. There were 5 questions where the trust scored better or much better than expected compared to other trusts. No questions were scored worse than the England average.
Many women praised their midwives for providing compassionate and hands-on support, especially during labour. Even when the services were busy, their presence made a meaningful difference. “The care that I have received at every point of my maternity care has been outstanding. I had a traumatic birth, but all staff seemed calm and professional, and we had confidence in them all.” Women generally described positive interactions with staff. However, some reported that staffing pressures affected the timeliness and consistency of support during labour and the postnatal period, including access to feeding support and emotional reassurance.
Some women reported delays in accessing treatment, including for tongue-tie services, (tongue-tie is where a piece of skin connecting the tongue to the bottom of the mouth is shorter or tighter than usual) with some families seeking private care. Some women also reported delays during elective induction pathways and would have welcomed clearer and more regular communication about their care and any changes to expected timescales.
Most women felt their pain was managed appropriately; however, some reported delays in receiving pain relief and would have welcomed more information about pain management options during labour. A small number of women also felt their concerns were not always fully addressed or that additional support could have been provided when they sought help.
Women were generally positive about the care they received. However, some highlighted opportunities to improve the ward environment and facilities, including cleanliness, bed availability and the postnatal ward environment, which could at times be busy and less conducive to rest.
Friends and Family Test results for August 2025 showed high levels of satisfaction, with 91.6% of 202 respondents reporting a positive experience of care."
Positive comments were received about community support from midwives and health visitors; women were very happy with the support and regular visits.
We contacted Healthwatch but they did not have any feedback about maternity services to share. Healthwatch is an independent statutory body, who listen to people’s feedback and report back to providers to improve standards of care.