Gloucestershire Royal Hospital

On this page

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

We looked for evidence that people and communities were always at the centre of how care was planned and delivered. We checked that the health and care needs of people and communities were understood, and they were actively involved in planning care that met these needs. We also looked for evidence that people could access care in ways that met their personal circumstances and protected equality characteristics.

This is the first inspection since maternity became a standalone service group. This key question was not included in the 2024 inspection of maternity services. This key question has been rated good.

This meant people’s needs were met through good organisation and delivery.

We have not awarded this service a score for Responsive.

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

The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Women received care tailored to their needs. Women reported staff discussed care plans with them, ensuring these reflected individual needs and preferences. Women had access to their electronic records, which we found to be comprehensive and indicative of personalised care, particularly for those with complex or high-risk pregnancies. Records included risk assessments for domestic abuse, deprivation, and substance use where relevant.

Women were referred to appropriate health and social care professionals as needed, and the mental health team confirmed there were clear referral pathways for specialist support.

A transitional care pathway was in place for babies who required additional clinical oversight was in place. Care was provided by the neonatal unit, delivery suite and the postnatal ward. This was part of the Avoiding Term Admissions into Neonatal units (ATAIN) programme. This is a UK-wide NHS initiative to reduce preventable admissions of full-term babies (born at 37+ weeks) to neonatal units, focusing on keeping mothers and babies together by improving basic care and identifying risks in areas like respiratory distress, jaundice, hypoglycaemia, and asphyxia. Information for women and their family/partners was available on the website about transitional care.

Women were supported by bereavement midwives and provided with clear, individual options for the disposal of pregnancy remains, following the death of their baby including burial or cremation. This approach demonstrated respect for personal preferences and cultural considerations.

The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Staff completed mandatory training which covered equality, diversity and inclusion and could seek advice from senior staff or the professional midwifery advocate (PMA) when needed.

Women received continuity of care before and after birth. Staff completed handovers, shared records, and referred women to community midwives on discharge. The trust monitored 1 to 1 care in labour, and it was within the expected standard range.

Community teams understood local health needs and worked with partner agencies to provide joined-up, continuous care.

Women and their families knew how to raise concerns, with clear information displayed in patient areas. Staff understood the complaints process, and managers investigated issues, identified themes, and shared learning to improve the service

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The service complied with the Accessible Information Standard and maintained confidentiality of patient records.

Staff provided clear, accessible information on treatments, local services, patient rights, and complaints processes. These were displayed on noticeboards and available in multiple languages.

Signage to the maternity unit was clear, and information was offered in understandable formats.

Interpretation services were available and used confidently by staff, supported by translation technology on the trust’s website and intranet. The maternity webpage included practical resources, though some content was outdated and did not reflect the closure of the Cheltenham birthing unit since 2022.

The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. But there was a delay in women and their family/partner obtaining a debrief which resulted in complaints taking longer to be completed.

The trust did not always respond to complaints in a timely manner. The trust had a quality improvement project to improve how they managed complaints. As part of this they had launched a pilot for complaints looking at early resolution where possible. This included early contact with the families and offering debriefs following traumatic events. However, there were delays in offering debriefs to women and their families which impacted on the resolution of complaints.

The service analysed patient experience data. Senior staff had undertaken a thematic analysis of maternity experience insight data. This reviewed complaints, national experience surveys and friends and family test results from June 2024 to July 2025. This identified areas of good practice and where improvements were needed. One of the areas they will be looking to improve is feedback from women whose first language was not English and to engage more with local population and communities.

We were sent details of a “you said, we did” relating to birthing options which included feedback from women and staff. For example, it stated how they were going to improve women being more involved in the discussions around their birth and to stop them feeling disengaged when they felt they were not involved. This was ongoing at the time of our assessment.

To encourage women to speak up and to get feedback about their care and treatment, senior staff have introduced Birth Experience Assessment by Matron (BEAM). This was where a matron would go around the ward and speak to women about their experience of giving birth.

The service made sure that people could access the care, support and treatment they needed when they needed it.

Women were able to access the service. The trust monitored the number of women booking their pregnancy by 10 weeks and by 13 weeks. Data up to August 2025 showed they were within the standard deviation. Once booked, women were sent ante-natal and scan appointments at the timed intervals. Information on how to contact the triage unit and other health care professionals was provided on the website.

The maternity unit at Gloucestershire Royal had remained open for the whole of last year and had not closed due to demands on their service where they could not accommodate any more women. However, the midwifery birthing unit at this location was closed when there were no women giving birth and staff re-deployed to other areas within this maternity unit. This happened during our site visit. The Cheltenham birthing unit remained closed. It was closed back in 2022 due to staffing concerns.

Women over 16 weeks pregnant were able to contact the triage unit if they had any concerns about their pregnancy. This was open 24/7 and women could call the advice line to speak with maternity staff who would advise them on the action they needed to take. There was access to medical care at the triage unit but at times women had to wait a long time to access this care.

Senior staff implemented measures to manage risks associated with planned inductions of labour. When the ward entered escalation, delays occurred and negatively affected women’s experience. To mitigate this, the number of planned inductions was capped at six per day. We reviewed the associated risk assessment and Standard Operating Procedure, which outlined the rationale and required staff actions. As the initiative was a pilot, outcomes were still under review at the time of our assessment.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Staff within the service and the wider organisation encouraged women using the service to give their views.

As part of their mandatory training staff received training in equality, diversity, inclusion and human rights.

Senior staff reviewed monthly dashboard data on ethnicity and deprivation among women giving birth to inform service planning. The trust had fewer mothers from the most deprived deciles at booking compared to the national average (8% in the most deprived and 4% in the second decile versus 14% and 13% nationally). A higher proportion of women were White (81% compared to 63% nationally), with lower representation from Asian or Asian British and Black or Black British groups than national averages.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Staff mostly worked in partnership with women regarding decisions about their care and treatment and their future.

Women and their families had access to a bereavement suite if they had a stillbirth or their baby died following birth. Specially trained midwives supported them and provided information for example, regarding funerals and postmortems if this was required. Senior staff told us they planned to provide bereavement training to all staff to help them when caring for a woman and their family following the loss of a baby. Information for women following the loss of their baby was available on their website.