Gloucestershire Royal Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

At our last assessment we rated this key question inadequate. At this assessment the rating has improved to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was a risk that people could be harmed.

The service was in breach of legal regulation in relation to safe care and treatment.

We have not awarded this service a score for Safe.

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

Incident reporting was not always completed promptly, resulting in a backlog of some incidents investigations. Limited staff training in the new national incident review system could contribute to delays in investigations, reducing opportunities to identify learning and mitigate risks to patient safety.

Staff understood their responsibilities for reporting incidents and were able to describe the reporting process. However, some staff working across maternity services told us operational pressures and workload demands could affect the timeliness of incident reporting. Incidents were recorded through an electronic reporting system and reviewed at daily weekday maternity safety flow meetings, where newly reported incidents, immediate learning opportunities, and overdue investigations were discussed. As of 15 October 2025, 39 incidents remained overdue for completion of an investigation. Following the assessment, senior leaders advised us these incidents had been classified as ‘low’ or ‘no harm’ and had been reviewed to identify any learning and required actions. Leaders expected this number to reduce to fewer than 30 by the end of October 2025. Incidents were also reviewed through the trust-wide Incident Response Safety Huddle (IRSH), providing executive oversight and identifying cases requiring escalation to the Patient Safety Review Panel.

During 1 of the site visits, we identified concerns regarding the care and treatment of a woman in triage. Senior staff undertook an immediate review, which was subsequently investigated through the trust’s patient safety processes. The review identified immediate safety actions and key learning themes, and the trust developed a safety improvement plan with named actions and timescales, which was shared with us.

Maternity incidents, including those resulting in serious harm or death, were reported to national reporting systems in line with requirements, although at times delays in reporting were identified. Leaders maintained oversight of incidents and commissioned external reviews to provide independent assurance, strengthen organisational learning, and support improvements in the quality and safety of care

The Patient Safety Incident Response Framework (PSIRF) was introduced in 2024. PSIRF is a process for services to respond to patient safety incidents for the purpose of learning and improving patient safety. At the time of our site visit only 1 member of staff had been trained in this system. Actions were being implemented to train more staff in the use of this system.

Senior leaders commissioned an independent external review of stillbirths and maternal deaths to provide additional scrutiny of clinical care and support organisational learning. The reviews had been completed and published before our site visit and identified both examples of positive practice and areas where further improvements were required.

The service used the National Perinatal Mortality Review (PMRT) Tool to review and report perinatal deaths. Senior staff told us these were reviewed at the PMRT group. We were sent copies of these following our site visits. We saw details of action plans and some of these included sharing the actions with other health care providers.

Most staff received feedback from investigation of incidents they reported. Learning from incidents was shared with staff in several ways including bulletins, e-mails and verbally at safety briefings during shifts.

Staff were debriefed and received support after a serious incident.

Information for women about how to make a complaint or provide feedback was available. Staff told us they knew the procedure to follow if a woman or their family/partner wanted to raise concerns.

Following our 2024 inspection, conditions were imposed on the provider’s registration due to concerns about maternity safety. While the provider had made improvements, progress towards achieving consistent compliance was protracted.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong. When senior staff reviewed incidents reported by staff they were also assessing if they met the duty of candour threshold.

The triage pathway was not always safe, with delays in some women receiving timely clinical review and treatment. These delays meant the service could not always provide timely access to care and treatment based on clinical need.

During the site visits the triage area was fully staffed and had an assigned dedicated doctor until 5.30pm who was supported by a consultant. The service had adopted the use of the Birmingham symptom specific obstetric triage system (BSOTS) which is an evidence-based risk prioritisation tool used in maternity services. The triage tool was used to assess how quickly women presenting with pregnancy related concerns should be seen, based on their clinical need. Staff used a colour coded rating system to prioritise care. Women should be seen by a midwife within 15 minutes of arrival, and a coloured rating should be allocated based on their presentation. Each colour identified how soon women should be reviewed by a doctor or midwife as required. The service provided audit data which demonstrated for August 2025 all women were seen within the 15-minute timescale on arrival to the triage unit which met the standard. However, there were occasions when women were discharged from the triage unit before their test results were available and were asked to wait at home for the outcome.

During our site visit we identified some concerns regarding the care and treatment of 1 woman. Senior staff reviewed the care and treatment of this woman and found areas for improvement to their service to reduce the risks to women. In addition, processes for following up women who did not attend triage were not always implemented promptly.

There was a process to monitor, review and prioritise women waiting induction of labour (IOL). A pilot was underway to reduce the number of IOLs to 6 per day and women were assessed by clinical need. A daily induction of labour huddle took place and was attended by medical and midwifery staff. A Standard Operating Procedure (SOP) was in the process of being agreed at the time of our assessment to provide guidance on how the induction huddle was to operate.

There was a ‘flow matron’ identified for every shift who managed staffing, flow and any acuity concerns across all trust maternity services. This was in addition to the labour ward coordinator. Staff we spoke with said they would refer any concerns to them. A matron of the day was available between 08.00 to 18.00 to provide operational support Monday to Friday. There was also an on-call senior manager outside of these times. The service remained fully operational and did not close to the public at any point between the months of July 2024 and July 2025.

The maternity unit operated 2 obstetric theatres. With increasing numbers of elective and emergency caesarean sections, senior staff were reviewing future capacity requirements to support timely care and a positive patient experience. The maternity unit operated 2 obstetric theatres. With increasing numbers of elective and emergency caesarean sections, senior staff were reviewing future capacity requirements to support timely care and a positive patient experience."

During the site visit we observed care in 1 of the obstetric theatres. During the observation, staff requested urgent assistance from the neonatal team and an emergency call or ‘code blue call’ was made. We timed this call and found it took 5 minutes for this team to arrive. We fed this back to senior staff as we were concerned about the amount of time taken by this team to respond to the call. In response, senior staff took measures to remind staff of the different emergency call types. The senior staff member said the response time for the call we observed was appropriate because the neonatal team were not required immediately.

Handovers and safety huddles across the unit involved all relevant members of the multidisciplinary team. Shift changes and handovers included all necessary key information to keep women and babies safe.

Women’s records were comprehensive and stored securely, with most documentation held electronically and accessible to women. Some documents, including medicine charts and consent forms, remained paper based. The maternity electronic records system was not integrated with other hospital record systems, which could limit access to information when women received care in other departments. Senior leaders were aware of this information-sharing risk and had recognised the need to address it.

Not all staff had completed their safeguarding training to the required level to minimise and mitigate risks to women and babies. This had been identified at previous inspections. However, the service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Not all staff were trained in safeguarding, but most staff understood how to raise alerts and acted appropriately. They knew who the safeguarding lead was and could seek advice when needed.

Safeguarding training compliance was incomplete. Compliance for obstetric and medical staff was at 49% for level 3 safeguarding adults and 22.2% for level 3 safeguarding children. This did not meet the trust’s target of 80%. This issue had been identified previously, and a warning notice was issued which the trust met at the inspection in 2024. This had been identified in the key issues and assurance report as high risk rated as ‘red’ and discussed at the Quality and Performance Committee in October 2025. This was also discussed at the public board meeting. The trust was developing an action plan to address the shortfall. Senior staff had identified this issue and discussed it at board level. Timely action was needed to further strengthen safeguards for women and babies."

Most staff identified adults and children at risk and worked with partner agencies to protect them. Procedures were in place to protect women and babies, including restricting visitors who posed a risk.

We reviewed 7 patient records and saw there was a system to identify women with safeguarding concerns. Staff were aware of this system and took appropriate action when necessary.

Women were asked safeguarding questions relating to domestic abuse during antenatal appointments, and we saw evidence of this within their maternity health records.

Systems, to maintain the safety of babies whilst on the unit, were tested several times a week to make sure they worked effectively. Staff told us they always responded to the alarms if they sounded.

Although people were supported to understand and manage risks, delays in treatment and inconsistencies in the delivery of personalised care meant that people did not always receive care in a timely or individualised way.

Staff communicated with women to ensure they understood their care and treatment. However, when a doctor was unavailable in triage, some blood test results could not always be shared immediately, which sometimes affected timely communication with women.

Staff understood risk management and used the Maternity Early Obstetric Warning Score (MEOWS) tool to identify women at risk of clinical deterioration. MEOWS is a recognised maternity care tool for monitoring pregnant and postpartum women.

Staff generally identified and responded to women at risk of deterioration. During the inspection, a woman in triage required additional review, which prompted a senior staff assessment. This identified opportunities to strengthen the timeliness of follow-up, escalation of concerning observations, and documentation, including when women did not attend appointments.

Following our 2024 inspection, we imposed conditions on the trust’s registration to improve safety for women and babies in maternity care. One condition required MEOWS to be completed for intrapartum and postnatal women in line with national guidance. The trust had shown staff were responding to amber scores appropriately and were repeating observations within the one-hour target. Across the maternity unit at Gloucestershire Royal Hospital the rolling average from April 2025 to August 2025 was between 90-95% within the target range.

Senior staff reported they had recently introduced a risk assessment tool to identify and manage the risk of pressure ulcers in women. This tool was in the process of being audited, and the service reported results indicated compliance had improved.

Senior staff acted to manage risks for women undergoing planned induction of labour (IOL). They identified when the ward was in escalation, this caused delays and negative experience of care. To address this, the number of planned IOLs was limited to 6 per day. We reviewed the risk assessment and Standard Operating Procedure (SOP), which explained the rationale for this decision and outlined actions for staff to follow. As this was a pilot it was still ongoing during our assessment and the result needed to be reviewed.

Staff told us about a tool they used a tool called SBAR which stands for Situation, Background, Assessment and Recommendation. This tool can be used for patient handovers, escalating clinical concerns, and facilitating clear communication between healthcare professionals. Staff in the maternity unit told us they used it for escalating concerns to doctors when there was a change in condition of a woman and/or their baby.

Staff were mostly alert to women’s needs and took time to observe, communicate, and engage with them about their immediate needs. For example, we observed midwives recognising and discussing women’s medical and emotional needs after difficult births. Most women felt staff recognised and responded appropriately to their pain and care needs, even when verbal communication was limited. Midwives took time to discuss birth preferences with women. Following the 2024 inspection, a condition relating to fetal monitoring was imposed on the trust’s registration. The trust strengthened hourly ‘fresh eyes’ peer reviews of fetal monitoring during intrapartum care in line with national guidance. Compliance averaged 90%, exceeding the 85% target and supporting the timely identification of fetal distress. A reduction to 65% was identified in October 2025. The trust had recognised this change and initiated an investigation to understand the underlying factors and support continued improvement; the outcome was not yet available at the time of our assessment. Senior staff also implemented a system to ensure staff accurately interpreted cardiotocography (CTG) traces and escalated concerns in line with trust and national guidance, promoting safe and effective care for women and babies. The data showed interpretation was at 90% and escalation for concerns 95%.

The maternity department identified and treated sepsis but not within the 1-hour timescale. People who are pregnant, given birth or had a termination of pregnancy or miscarriage in the last 6 weeks were identified as high-risk for sepsis. Sepsis is a serious condition that occurs when the body’s immune system has a dangerous reaction to an infection. An audit of the management of sepsis was undertaken in September 2025. A sample of 10 women’s records out of 28 were selected who had suspected sepsis. This examined 7 areas and 1 of these was if staff achieved the sepsis bundle within 1 hour. Six out of the 10 met the 1-hour target. This still meant 4 women had not had the sepsis bundle completed within the timescale. Action was needed to improve this. The service planned to set up a quality improvement project to monitor compliance against sepsis management.

Out of the 8 conditions we imposed, 1 related to the lack of completion of assessments for women’s risk of Venous thromboembolism (VTE). VTE is the blockage of a vein caused by a clot. A common form of VTE is deep vein thrombosis, when a blood clot forms in the deep veins. If a clot breaks off and flows to the lungs to lodge there, it becomes a pulmonary embolism, a blood clot in the lungs. Senior staff had been monitoring the completion of VTE risk assessments. Data sent to us shows staff were now mostly completing these risk assessments. This was an improvement from the last inspection.

The trust could not provide data for decision to incision or ‘knife to skin’ for caesarean sections due to an issue with their electronic patient record system. Decision to incision or "knife to skin" is when the first incision is made into the woman’s abdomen and classed as a critical procedural point that involves careful monitoring for both the mother's protection against infection and the baby's protection against injury. They were working to address this but reported they had 5 incidents in 12 months but there were no safety concerns involving the woman or their babies.

The service had arrangements to identify and manage environmental risks. Further work was underway to ensure equipment, facilities and technology consistently supported the safe delivery of care.

The maternity services at the hospital consisted of an antenatal clinic, obstetric day unit, triage, labour ward including 2 maternity theatres, birthing unit and maternity ward. A bereavement suite was included on the labour ward. The unit was open 24-hours a day, 7 days a week and was fully secure with a swipe card entry and exit system monitored by ward clerks and maternity staff. During site visits, entry to all areas within the service was monitored appropriately by staff who had details about visitors who could not access the unit.

The service had assessed risks within the triage environment and recognised they needed to strengthen oversight of the waiting area, including spaces near the lifts, to support patient safety. Prior to our visit, some women reported waiting between 4-7 hours to see a doctor, not seeing any staff during this time and sitting on uncomfortable chairs. Following the site visit, senior staff completed a risk assessment of the triage seating area and implemented additional measures to further strengthen safety. These included 30‑minute intentional rounding, whereby staff regularly checked on women in waiting areas and maintained records of these reviews. Women received an initial assessment within 15 minutes of arrival and were prioritised according to clinical need. Senior leaders also developed a targeted action plan to support ongoing improvements within triage.

Equipment and furnishings were generally well maintained. During the inspection, a small number of items requiring attention were identified, including a damaged chair, some expired blood collection bottles and consumable items, and a breast milk fridge awaiting repair. These were promptly escalated to senior staff, who took immediate action, including removing expired items from use and implementing interim storage arrangements for breast milk while repairs were completed

Emergency equipment checks were routinely completed across the service. During the inspection, we noted some gaps in the documented checks for emergency trolleys across the maternity unit. On the birthing unit it was unclear whether these related to periods when the area was closed, as this was not recorded. As the birthing was closed during the site visit, we checked the emergency trolleys we could not ascertain the reasons. This presented an opportunity to further strengthen documentation and provide additional assurance of equipment oversight

We saw a ligature risk assessment for the ward, demonstrating that potential risks had been considered. Ligature cutters were readily available to staff in the emergency trolleys, supporting a prompt response should an emergency arise.

The service experienced some staffing pressures in both midwifery and medical teams. At times, increased demand affected access to timely medical review, and work was ongoing to strengthen the responsiveness of care

The trust used agency and bank midwifery staff to maintain safe staffing levels when necessary. At the last inspection, we imposed conditions on the trust registration to implement an effective system for ensuring agency midwifery staff had a comprehensive induction to the unit, were able to access the maternity electronic records system and trust policies, as well as enter and exit the unit without delay. At this inspection, we found the service had improved. Senior staff from the trust told us and we saw evidence that agency staff had an induction to the unit, were told about systems and had to access pass keys to safely move around the unit.

The service had increased triage staffing in response to growing demand, supported by bank staff. Rotational Band 5 midwives worked within the triage team and received supervision from experienced senior staff to support their development. The service recognised opportunities to align staffing arrangements with Royal College of Obstetricians and Gynaecologists guidance, which recommends experienced Band 6 or 7 midwives in triage to support specialist assessment and decision-making

Community staff reported staffing shortages in Gloucester, with midwives redeployed from other geographical community areas to fill gaps. This affected staff wellbeing. Community midwives escalated concerns to the hospital flow matron, but bank and agency staff were rarely used, as community teams were responsible for covering the gaps despite the geographical location. On call shift were usually planned between working days so time off was not interrupted. Staff told us there were times they travelled all over the county to cover home births and it could take over 1 hour to reach the women’s home. We were not told if there were any times where they missed the birth due to travel.

Staff on the antenatal/postnatal ward reported frequent shortages of midwifery support workers (MSW), causing delays in responding to call bells. Increased acuity, including more caesarean sections, further impacted capacity. Staffing concerns were escalated to the flow matron, who redistributed staff to cover gaps. However, staff said the acuity tool frequently flagged ‘red’ at night without action, and redeployment to other areas reduced ward staffing further. Staff were also concerned about the removal of the qualified nurse post, which they felt supported care for women with medical conditions.

Senior leaders used a recognised national midwifery specific staffing tool to review staffing. This staffing review took place in 2023, and it recommended to review every 3 years. The tool used reviews clinical activity within the unit to be able to ascertain the safe number of midwives and maternity support workers required within the unit.

Senior staff monitored ‘red flags’ in maternity staffing monthly. A midwifery red flag event is a warning sign that something may be wrong with midwifery staffing. In September 2025 the number of red flags recorded was 11 and staffing factors was 478. These included delays in providing pain relief and unexpected staff absences. An action plan had been devised to improve compliance with red flag incidents. The monitoring of red flags included 1 to 1 care in labour. We reviewed data for the period between August and September 2025 which showed there were no red flags meaning women all had 1 to 1 care during their labour. Data showed between October 2024 to March 2025 1 to 1 care for women in labour was achieved 98% of the time. This indicated maternity services had sufficient staff in the labour department.

Student midwives were allocated to the unit; however, staff reported challenges in securing mentors, largely due to a predominantly junior workforce and the additional supervisory demands on senior staff.

The maternity unit at Gloucestershire Royal Hospital had not been closed in the last 12 months to admissions. However, the midwifery led birthing unit was closed when they had no women giving birth and staff re-deployed to other areas. The birthing unit at Cheltenham had been closed since April 2022 due to not being able to staff the unit safely.

The service ensured 24-hour medical cover and provided a dedicated doctor within triage until 5.30pm. Women could access medical review when needed; however, some reported delays in triage assessments and reviews during periods when medical staff were managing demands across the wider service. Consultants provided support across several maternity services whilst on duty, including unscheduled care and elective caesarean section lists. Although this enabled flexible clinical leadership across the service, it occasionally led to delays in consultant reviews during periods of increased demand.

Staff had received and were mostly up to date with mandatory training and training appropriate for the patient group using the service. Senior staff predict they will be at target by October 2025. All staff had 3 mandatory training days per year. However, if staffing was below numbers on any of the unit staff could have their training cancelled. The service had a process to determine how urgent completion of mandatory training was before pulling staff from training to work in the service.

Senior staff were looking at different methods on how to reach and engage staff for training on different topics to meet all training needs, for example, trolley teaching (where they take a trolley to each area and teach staff whilst on duty), emails, and a closed group social media channel.

The service had a flow coordinator midwife on every shift. Flow coordinators were supernumerary and had oversight of the staffing, acuity, and capacity within the unit. They reviewed and adjusted staffing levels and skill mix daily according to the needs of women.

We reviewed recruitment files for employees and found the trust was compliant with the necessary regulatory requirements. Staff had the necessary checks before commencing employment with the service to ensure they were suitable to support women and babies.

International midwives had been appointed and told us they felt well supported by staff throughout the unit and had an induction programme based on their needs.

Unqualified staff were able to apply for courses to help them train as a midwife and were supported by senior staff to do this. This was part of retention and recruitment plan.

Qualified staff had their registration details checked, and a system was in place to monitor this. Also, a process for monitoring revalidation was established and compliance was regularly reviewed.

The sickness rate for nursing and midwifery staff in the maternity core service saw sustained reduction from 5.9% in December 2024 to 4.1% in April 2025. This then rose again in the most recent month of June 2025 to 5.5%. This was still an improvement from the elevated sickness rates experienced by this staff group around May 2024 which sat at 7.1%.

However, sickness rates for medical staff working within maternity services had been increasing since September 2024, although sickness rates remain lower in this staff group. The highest monthly sickness rate was recorded in March 2025 at 3.8% and had dropped to 2.6% in the latest month (May 2025).

The numbers of staff leaving the service peaked in September 2024 (10.3%), the service told us this had reduced to much lower numbers, with the lowest recorded across the period in the latest data available (1 in July 2025), however we were not provided with evidence to support this.

The service did not consistently identify and mitigate infection prevention and control risks associated with staff compliance. Monitoring of adherence to the uniform policy was not routinely undertaken, limiting assurance that infection prevention and control standards were being consistently maintained.

Staff adhered to infection control principles, including handwashing. However, not all staff followed the uniform policy. For example, wearing false nails, nail varnish and rings with stones in them. This was an infection control risk to women and their babies. This was reported to senior staff during our site visit.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date in the hospital setting. In the community, midwives had access to hand gel and could wear scrubs at home births. All equipment used at home births was placed in the appropriate bags or containers and transported to a location for safe disposal.

Staff had access to domestic and clinical waste bins, and these were emptied regularly. Sharps and hazardous waste bins were stored safely.

Hospital areas were clean, furnished, and generally well-maintained. However, we found a chair in a birthing room with a torn seat, posing a cross-infection risk, which was reported to senior staff.

Hand hygiene compliance showed a unit average of between 95% to 100% for the months June to August 2025.

The service ensured that medicines and treatments were safe and met people’s needs, capacities and preferences. However, medicine administration records were not always fully completed. Also, limited clinical pharmacy support reduced assurance that medicines were managed safely.

Medicines were prescribed on paper charts. We looked at 6 medicine charts and found allergies and weights were always documented to ensure medicines were prescribed safely. However, we saw 3 medicine charts were not always fully completed, for example, we saw dates were not recorded for medicines to be administered and the route of administration for the medicine was not recorded. This could lead to confusion such as whether a dose had been administered or not.

There was no clinical pharmacy support for the maternity service. There was no evidence to demonstrate if medicines reconciliation was carried out. Medicine reconciliation is the process of accurately listing a person’s current medicines. Medicine reconciliation helps to prevent medication errors like omissions, duplications, or incorrect dosages. All women had anticoagulants prescribed correctly according to their weight, and there was additional guidance printed on the prescription charts to guide prescribers.

Prescribers and midwifery staff had access to resources to ensure medicines were prescribed correctly. However, we found 1 example of a Patient Group Direction (PGDs) not in place and further examples where staff were practising using out-of-date PGDs. This did not meet the trust’s own policy and national guidance. PGDs are written instructions for named healthcare professionals (like midwives or nurses) to supply or administer specific medicines to patients who fit defined criteria, without a doctor's prescription for each patient.

Medicines, including controlled drugs (medicines requiring additional control due to the potential of misuse) were stored securely. Improvements had been made for the labelling of medicines in theatres to avoid errors. Room, fridge and freezer temperatures where medicines were stored were monitored and staff we spoke with understood when to escalate. The required emergency medicines were held in stock and checked regularly.

Discharges were mostly carried out from the ward, with the use of prepacked medicines to facilitate rapid discharge. There was a discharge checklist, which included counselling women on how to administer their anticoagulant injections as required.