Gloucestershire Royal Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

At our last inspection we rated this key question Good. At this inspection we assessed 4 quality statements and the rating has remained the same. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

Staff comprehensively assessed people, so the care and treatment provided met their needs. This included both their mental and physical health and any personal circumstances that needed to be considered. Staff worked in a strong culture of evidence-based practice. Staff worked together and with others when assessing people's needs and shared information to maintain continuity of care.

We have not awarded this service a score for Effective.

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

We did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

We scored the service as 3. The evidence showed a good standard. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Staff used the trust's systems to follow the latest guidance and evidence-based practice. Staff had access to trust policies and standard operating procedures on the electronic system. Speciality teams provided an in-reach service to the Same Day Emergency Care (SDEC) and Acute Medical Unit (AMU) for people who require their input. Staff said these teams were responsive. We reviewed trust policies and found most policies were in date.

The medical care service had access to a full range of specialist teams to meet service users needs, including doctors, nurses, pharmacists, physiotherapists, speech and language therapists and dietitians. Most service users told us they felt well supported and described staff as considerate and compassionate. Physiotherapy staff explained that their primary focus was preparing people for safe and timely discharge. However, some physiotherapists said they would also welcome greater capacity to support patients in maintaining mobility and preventing deconditioning during their hospital stay. Deconditioning refers to the decline in a person’s physical and mental functioning as a result of prolonged inactivity or bed rest.

Staff gave people clear information about their care and treatment needed to support both their physical and mental health. Staff met people's nutrition and hydration needs. We saw staff supporting people who were unable to feed themselves at mealtimes. They mostly used effective tools for screening malnutrition and dehydration however, we observed one service user who had not had an assessment carried out for over 1 week, despite the fact that the patient required a Nasogastric feeding tube. We raised this issue during inspection, and this was rectified at the time.

Staff participated in clinical audit, benchmarking and quality improvement activity. Evidence showed that routine observations were generally completed within required timeframes. An audit of NEWS2 (“National Early Warning Score”) documentation demonstrated that patients scoring above 5 were appropriately escalated for medical review. On the respiratory ward, staff used an electronic system that clearly flagged when observations were due. During our inspection, we noted a patient triggering a red alert and found that staff were already undertaking the required observations when we arrived.

NEWS2 provides a structured method for identifying patient deterioration by scoring 6 physiological parameters, including respiratory rate and oxygen saturation. Despite good escalation practice, the trust recognised a significant divisional challenge with completing NEWS2 assessments within one hour of a person's admission to the ward. Work was ongoing to improve compliance with this requirement.

Staff on the respiratory ward were part of a quality improvement pilot to support early discharge for service users. This involved all necessary steps for a service user to be discharged being completed within 1 hour of the person being identified as fit for discharge. We had good feedback on this initiative from staff who said it was supporting patients to be discharged at an earlier time in the day, meaning beds were available for other patients.

We scored the service as 3. The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff effectively handed over people’s assessed needs when individuals moved between different services within the hospital. Most service users were discharged safely either home or to social care placements. However, there were instances where discharge processes were not fully effective — for example, service users leaving without their required medicines or discharge summaries. The trust was aware of these issues and had implemented a continuous improvement plan to reduce the likelihood of such occurrences.

Staff held effective multidisciplinary meetings and had effective working relationships which included good handovers with other relevant teams within the organisation. For example, the discharge lounge worked well with the medical wards and visited people that were due to be discharged in order to tell them about the service and to set expectations.

Patients with eating disorders who required medical treatment were being cared for in an acute setting that was not suitable for their needs. This occurred because there were no appropriate community placements or mental health inpatient beds available. As a result, the acute trust became the only option, despite the environment not being designed for this type of care. Trust staff were engaging with the local mental health trust and the integrated care board (ICB) around these issues. Staff told us about one patient with an eating disorder who remained on the Acute Medical Ward for four months. These service users often required nasogastric (NG) feeding, which could be highly distressing for both the patient and staff, as the procedure sometimes required the service user to be safely held while the tube was inserted. These ‘safe holds’ were undertaken by the enhanced care team. The challenge of caring for people with eating disorders in unsuitable acute settings is a recognised national issue.

Staff had access to the information they needed to assess, plan and deliver people’s care, treatment and support. Relevant staff were able to access electronic patient records through secure log‑ins, which supported timely decision‑making and continuity of care. However, we were told there were ongoing difficulties accessing information held on General Practitioner (GP) systems. This meant staff did not always have full oversight of a person’s needs when coordinating care across services. For example, service users on the Virtual Ward who required visits from the hospital‑at‑home team were not always aware of safeguarding information recorded by primary care services. This created a risk that important safeguarding alerts were not consistently visible to staff involved in the person’s care.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

We scored the service as 3. The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

We found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance. The service had access to diagnostic and support services 7 days a week. Medical staff we spoke with said that there was good access to services to support patient treatment and care. The SDEC unit had medical cover during the working week and used Advance Practitioners to carry out initial medical tests and assessments which ensured the necessary information was available when the consultant reviewed the service user and enabled the consultants to see more people.

Staff recorded service users notes fully and accurately, using recognised tools to support the early detection of clinical deterioration and ensure appropriate responses. Our review of records showed good compliance with completing required assessments and taking timely, evidence‑based actions when patients deteriorated. Audit data demonstrated that patients with suspected sepsis received antibiotics within one hour, with strong compliance with the Sepsis Six bundle—a set of six time‑critical interventions designed to improve outcomes for people with sepsis.

We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) and ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) decisions were appropriate and were made in line with relevant legislation. We reviewed patient records, all of which had completed ReSPECT forms.

Staff took all practical steps to enable people to make their own decisions. We reviewed service user notes and saw people who had impaired mental capacity were assessed in line with legal frameworks.