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 this assessment, the rating was requires improvement. We identified some issues with the environment, including a lack of toilets and an ageing estate and staff who did not conform with the trust’s infection control measures for hand washing, mask wearing and being bare below the elbow. However, patient areas were safe, and staff assessed and managed risks to patients and themselves well. Staff understood how to protect people who used services from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.

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.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff were confident to report incidents and knew what to report and when. Staff we spoke with said they were comfortable reporting incidents and had received feedback on the incident after reporting it. The trust had an improvement group, consisting of managers, which focused on the removal of barriers to help staff report incidents quicker and easier. This had been established because the trust had noticed a reduction in incident reporting.

Staff understood the duty of candour regulation and the need to be open, honest, and transparent with people when things went wrong with their care.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The hospital, like many others, faced significant operational pressure and demand across its Medical Care and Urgent and Emergency Care services. Average bed occupancy was high at 92% however the trust had various initiatives to support discharges out of the hospital which were helping the medical department perform slightly better than other hospitals nationally. As with all trusts nationally, there were still many people who used services that remained at the hospital, despite being medically fit for discharge, because there were no onward packages of care available in the community. As of December 2025, data showed the total number of people who used services at the trust with no criterion to reside as 112. This figure as a percentage was similar to other South West hospitals.

Staff told us that non-clinical spaces (also commonly known as corridor care) was not routinely used within the medical wards. Corridor care refers to admitting people who used services into areas not designated as clinical spaces. Although we observed some corridor spaces being used in the Acute Medical Unit during our visit, we were informed that this was an exception rather than usual practice. Medical wards did not typically board people who used services or use corridor spaces for care. Boarding a person who used services refers to the practice of adding additional beds into a ward at times when capacity is limited. The trust had policies that stated corridor care could only be used during critical or major incidents, and any people who used services placed in a non-clinical space must have a confirmed discharge plan and remain for no longer than two hours. The trust did not always manage to adhere to their policy in terms of time when people who used services were in non-clinical spaces. Any use of corridor care was escalated to senior management during the site team meeting. People who used services that were discharged and then readmitted within 30 days were reviewed.

The trust held bed meetings 4 times a day to review patient flow and escalate any cases experiencing delays. The trust also held safety briefings each day and a Silver / Gold command handover at 5pm each weekday. The Gold - Silver- Bronze command structure is the UK’s nationally recognised framework for strategic, tactical and operational command during major incidents, used by police, fire, ambulance, NHS, and other emergency agencies. Leaders told us this approach was effective, as it supported coordinated flow through strong multidisciplinary collaboration. Wards submitted up-to-date bed and discharge information ahead of each meeting to support timely decision-making.

Communication between the Acute Medical Unit (AMU), Emergency Department (ED) and the wards was generally positive, helping ensure people who used services were transferred promptly to the appropriate speciality wards. Each morning, ED identified people who used services that were suitable for speciality transfer and communicated these to the relevant wards to support safe and efficient flow.

The discharge lounge supported flow through the hospital and could accommodate up to 30 service users in beds as well as service users who were fit to sit in chairs. Staff worked effectively to facilitate on-the-day discharges including liaising with the pharmacy department to ensure medicines to take home were ready. The discharge lounge opened at 06.30 in the morning. Staff said communication between the discharge lounge and the wards was positive. Staff from the discharge lounge would visit service users on the ward who were due to transfer to the lounge the next day to explain the process. There were clear criteria outlining what service users must have in place before they can be transferred to the discharge lounge. These requirements varied depending on the trust’s escalation level — for example, the criteria for OPEL (operational pressure escalation level) 1 and 2 differed from those applied when the trust was operating at OPEL 3.

The Same Day Emergency Care (SDEC) unit and the Virtual Wards helped to support safe flow of service users through the hospital by avoiding admissions into the hospital. Medical Virtual Wards aimed to provide safe, high-quality, hospital-level care for acutely ill service users in their own homes, acting as a substitute for traditional inpatient stays. The key goals included preventing unnecessary hospital admissions, accelerating service user discharge, improving service user's experience/outcomes by enabling recovery in familiar environments, and increasing system capacity.

The primary aim of SDEC was to provide rapid assessment, diagnosis, and treatment for emergency service users on the same day they arrived, avoiding unnecessary overnight hospital stays. It aimed to improve people who used services experience, reduce Emergency Department crowding, and lower infection risks. We received positive feedback on both services. The Virtual Wards had an average admission of 62 service users a month. There were 5 medical Virtual Wards supported by a central hub and a hospital at home team.

Staff were clear about how to escalate concerns when a patient’s condition deteriorated. On the respiratory wards, an electronic dashboard was used to alert staff when observations were due. During the inspection, we saw a patient with an increasing National Early Warning Score 2 (NEWS2) being monitored at required intervals, with timely escalation to the consultant in line with clinical protocols. NEWS2 is the nationally standardised system for recording, scoring and responding to changes in physiological observations in acutely unwell service users, supporting early recognition and management of deterioration. The trust had daily incident huddles and a weekly Patient Safety Review Panel. This reviewed any episodes of missed deterioration for appropriate response and learning. The respiratory ward had clear escalation plans for patients and Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms had been completed. A ReSPECT form is a document used in healthcare to outline a person’s emergency care and treatment preferences.

The service’s referral and admission processes ensured that staff received all essential information needed to determine whether the service users needs could be safely met. Service user records were maintained on an electronic system, which supported timely access to relevant information. An audit of notes showed generally good compliance with completing key risk assessments; however, several areas required improvement across the division. Completion of alcohol assessments was below 75% on most medical wards. Compliance with completing a falls assessment within four hours of a patient transferring from another ward and completing a post‑fall assessment within four hours often took longer to complete. Timeliness of enhanced observations required improvement to ensure care was delivered in line with clinical need.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Staff received training relevant to their role on how to recognise and report abuse. They understood how to raise alerts and acted appropriately. There was a safeguarding policy. Staff knew who the safeguarding lead was and could seek advice when needed. The electronic patient system had alerts for people who had safeguarding concerns. Staff knew how to access these alerts. However, there was sometimes an issue with how safeguarding alerts were shared across local providers to ensure all information was shared and staff were aware of any safeguarding issues.

Safeguarding training compliance was above 75% for all staff. Safeguarding adults Level 1 and 2 were above 90% with safeguarding adults Level 3 at 76%. Safeguarding Children Level 1 and 2 was at 89% and 79% respectively.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff mostly communicated with people who used services so that they understood their care and treatment. We generally received positive feedback from service users. One service user stated they ‘felt informed and able to make their own decisions regarding their care.” We did however have feedback from a service user who had communication difficulties and felt they were missing out on understanding what care was being delivered and why.

Leaders and staff could articulate what risk assessments they used to keep patients safe. An audit of patient notes showed generally good compliance with completing key risk assessments. We reviewed care plans and saw that there was good compliance with completion of Recommended Summary Plan for Emergency Care and Treatment (ReSPect) forms.

People were able to give feedback on the service they received. In the adult inpatient survey conducted in 2024 the service ranked higher than the national average for staff taking into account patient individual needs.

We scored the service as 1. The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The environment of the hospital was old. Some medical service users were located in the Tower Block such as respiratory service users based on the 8th floor and there were concerns around the ease of evacuating these people in an emergency. The hospital had recently experienced a fire on the respiratory ward a month prior to our inspection where it had successfully evacuated people from this ward without any harm to service users, however this still remained a concern. The senior leadership team were undertaking mitigating actions such as having a member of staff throughout the day, risk assessing the Tower Block environment. The hospital was also undertaking a refurbishment of the Tower Block, which would span over a 4 year period.

The bathroom facilities were not always adequate for the number of people on each ward. At the time of our inspection, we found 2 bathrooms on the elderly care wards out of order. This meant service users could not access facilities to wash independently and this was being carried out at the bedside. Both these bathrooms were being used to store large amounts of equipment. One of the bathrooms, on a 4-bed people bay, had been out of use since May 2025 and we noticed an unpleasant odour coming from this room. We observed not all side rooms on the respiratory wards had ensuite toilets. These side rooms were often used for infectious people which meant they had to attend to their personal care in their own room which did not promote independence, privacy or dignity. We spoke with staff who said this was not ideal, however in terms of the side rooms, they were not sure what steps the trust could take to improve this situation. One patient on Ward 8B stated “there was nowhere to wash or shower and the ward was very dirty”.

Not all of the equipment and environments we inspected were clean and secured. For example, we found visible dust between the fridge and the cleaning cupboard in the clean utility on the respiratory ward. We also observed 2 computers left unattended which could lead to a possible information governance breach. Equipment was regularly checked and electrical safety checks on most portable appliances had been carried out. We did find some Christmas lights that had not been checked, these were immediately turned off and reported.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people's individual needs. Staffing was planned and managed according to national guidance. Leaders used recognised staffing tools to ensure that there was enough staff to deliver care and treatment.

Staffing was reviewed 2 to 4 times a day. If extra staff were required for one to one care and the ward was going over its capacity, this was approved by the matron. Staff said they were able to get additional staff when needed.

Nurse staffing levels were close to full establishment with a low vacancy rate of under 2% for Band 6 nurses and 3.3% for Band 7 Nurses. Band 5 nurse vacancy rates were also low at 3.36%. We saw records which demonstrated that the trust was able to fill the shifts required for this band of staff across the medical division. As with most trusts the vacancy rate for health care support workers was higher at close to 19%. The divisional sickness rate was at 4.33% at the time of the inspection which is satisfactory when compared to other trusts in the south west area.

Medical cover was mostly appropriate to ensure people had regular consultant oversight. Medical cover for Virtual Wards had been increased from 1st October 2025 and there was now medical cover 5 days a week. The trust hoped this would help the Virtual Wards to increase the number of people they helped and ensured that a medical prescriber was available for more complex patients. Staff said weekend cover was sometimes problematic as locum shifts were not always filled.

There were opportunities for development and staff received appraisals. From data received by the trust for November 2025, only 1.5% of staff had not received an appraisal. The system that recorded the status of appraisals, alerted staff and managers when these were due. The trust had also recently reviewed its non-medical appraisal process in July 2025 to ensure a shared understanding and consistent approach to carrying out non-medical appraisals. We talked with staff who said they had been supported to develop their skills and competencies in order to progress in their careers.

Staff completed mandatory training, such as training on resuscitation and infection prevention control. The division overall had a compliance target of 90% and the medical division was just below this target at 89% as of November 2025. This was for nursing and medical staff.

We scored the service as 1. The evidence showed significant shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

Staff did not always adhere to infection control principles, including hand washing. We observed staff not washing their hands between patient contact and some did not adhere to the trust’s policy of being bare below the elbow. We saw some staff wearing watches and some who had false nails. We raised this with the senior management team who were aware it was an issue and were working to ensure staff were compliant with trust policies. Hand hygiene audits did show staff were compliant with good practice however, our observations during the inspection period did not support these audits. Not all hand hygiene audits were completed in line with the trust’s audit schedule.

We were not assured all areas were cleaned regularly to ensure there was no risk of infection spreading. For example, we reviewed the cleaning folder for the Acute Medical Unit (AMU) and found for November 2025 there were 8 days that had no entry against them. We were told by staff nurses that there should be an entry completed once for every shift. We also found areas which were not visibly clean.

People who required isolation rooms due to infections were mostly able to be nursed in side rooms. The service tested service users in the Emergency Department for infection and alerted the wards if a person was infectious. The same applied for people attending the Same Day Emergency Care (SDEC) unit if the person was referred by the hospital. However, if the person was referred by the GP surgery, their infectious status was not always known.

Most staff adhered to effective barrier‑nursing practices, and clear signage was displayed outside patient rooms to indicate required infection‑control precautions. However, we observed inconsistent compliance with Personal Protective Equipment (PPE) requirements when staff entered isolation rooms. In one example, a room displayed a clear instruction that an FFP3 (filtering face mask) was required, yet three staff members entered the room—two wearing only surgical masks and one wearing no mask. We also observed a staff member who did not change their mask after leaving the room. An FFP3 mask provides a higher level of respiratory protection and is designed to filter at least 99% of airborne particles. This meant staff did not consistently follow PPE guidance to minimise the risk of cross‑infection.

The trust monitored the number and types of infections seen in the hospital. The Trust had a C.difficile infection reduction plan for 2025/26 focused on reducing contamination and reservoirs of C.difficile, improving early identification and management, strengthening antimicrobial stewardship, improving the built environment, and improving system working to prevent recurrence and safeguard those at risk in the community. The Trust reported 95 cases against the NHS England threshold of 97 for 2025/26 and, in NHS England surveillance reporting to February 2026, had the lowest rolling 12-month C.difficile rate per 100,000 population across the South West.

The trust had an Infection Prevention and Control team that provided strong support to the division in managing patient-related issues or outbreaks. Divisional staff gave positive feedback about the team, describing them as responsive, accessible and supportive.

The service had safe systems for the appropriate and safe handling of medicines; however, we saw that these were not always consistently followed by staff.

Medicines for use in an emergency were available in emergency trolleys. However, staff were not following trust policy and undertaking regular, systematic checks of these trolleys to ensure these medicines were suitable for use when needed. This meant we could not be assured medicines were suitable for use in an emergency.

Additionally, staff were not always following trust policy in relation to temperature monitoring of medicines. We saw no evidence that staff took action when medicines were stored outside the manufacturer's recommended conditions. This meant we could not be assured that medicines, such as antibiotics, were always suitable for use.

Nursing staff told us that they were happy with the support they received from pharmacy and were always able to contact them when needed regarding medicines queries. We saw that medicines, including controlled drugs were stored securely on the wards.

Pharmacy staff used a data led red, amber, green (RAG) rating tool to support them to prioritise aspects of the service to manage staffing capacity issues and attempt to mitigate the risk of reduced capacity. This tool was able to pull data from various electronic systems to support planning.

Pharmacy staff prioritised medicine reconciliation (the process of accurately listing a person’s current medicines) for people with time-critical or high-risk medicines identified on the electronic prescribing and medicines administration system. However, audits showed that targets for medicines reconciliation were often missed on some wards, staff told us this was due to staffing. The most recent figures available showed 58% completion of medicines reconciliation within 48 hours of admission in one part of the service.

Staff told us that a pilot of having a pharmacy clinical service available to the Acute Medical Unit at the weekend had been well received. Risks associated with delayed review of medicines were reduced, and continuity of care across the weekend-to-weekday transition was improved. Unfortunately, this service had not been continued beyond the pilot stage due to funding.

Processes were in place to ensure people received time critical medicines at the correct interval. These included alerts on the electronic system and a specific cupboard to enable quick access to these medicines. However, we saw that Parkinson’s medicines and antibiotics for one person were significantly delayed, the pharmacist took action to ensure these were administered.

The service had systems to ensure staff knew about medicines safety alerts and incidents. We saw that reported incidents were monitored, reviewed, and where required, changes to practice were implemented.

A cycle of medicines related audits was in place. Results were used to support improvement work in medicines optimisation. Work from these audits was presented at directorate meetings.