Gloucestershire Royal Hospital

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• 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

Description: We looked for evidence people and communities had the best possible outcomes because their needs were assessed. We checked people’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring people were at the centre of their care. We also looked for evidence leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

At our last assessment we rated this key question good. At this assessment, the rating declined to requires improvement.

The service did not consistently deliver effective care. Many clinical guidelines required updating, and care for high-risk sepsis patients was not always timely. Multidisciplinary working was hindered by specialties not consistently attending the emergency department in line with Getting It Right First Time (GIRFT). Getting It Right First Time is a national NHS England programme designed to improve the treatment and care of patients through in-depth review of services, benchmarking, and presenting a data-driven evidence base to support change) standards, causing delays in patients moving to the right clinical area.

Outcome monitoring was weak: improvement plans lacked progress, triage performance was inconsistent, delays for older people and long emergency department stays remained significant, and there were high levels of delay‑related harm.

Consent processes were not reliably embedded, with low mental health training compliance among medical staff, gaps in mandatory training, and no regular audit of consent documentation.

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.

The service did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.

Staff and leaders were not up to date with current legislation, national standards and evidence-based good practice guidance relevant to their service. The emergency department portal contained over 200 individual guidelines divided into categories. In 2025 a comprehensive review of the guidelines was performed. It was apparent many of the guidelines required review. Emergency department consultants were asked to take certain categories and initiate a review and update processes, liaising with specialities as required. This was currently a work in progress with a deadline of mid-2026.

Care for high-risk sepsis patients was not always timely and effective (as discussed in safe systems, pathways and transitions in the safe domain).

The team included or had access to the full range of multi-disciplinary teams required to meet the needs of patients in the service. As well as doctors and nurses, the department had support from the Community Assessment Team. The Community Assessment Team consisted of occupational therapists, physiotherapists and support workers. They were employed by a local community NHS trust and worked in partnership with the emergency department.

Not all staff were always up to date with their required training to ensure they had the right skills and knowledge. Managers identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge. Managers usually ensured staff received the necessary specialist training for their roles. Staff received additional training for their roles through structured programmes and senior supervision.

The percentage of staff who had had an appraisal in the last 12 months was 77%. This was the compliance rate for all staff working across both emergency departments. Managers dealt with poor staff performance.

Staff assessed and met patients’ needs for food, drink and hydration. We observed a food trolley delivered to the emergency department. Nurses told us they would offer food to patients in order of longest waiting time. There was a drinks trolley in the waiting area where patients could help themselves. There was also water available for patients nursed in the corridor, but it needed to be offered as there were no individual tables for them.

Mental health guidelines were followed, including access to the mental health liaison team based within the department. There were appropriate developmental assessments for children and young people. The mental health liaison team completed mental health risk assessments at triage with physical, mental, and social assessment of patients and children. Older or frail patients were referred for comprehensive assessment by the mental health older adults’ team.

Public health screening was conducted in the department, for example, for influenza and Covid-19. If patients tested positive, they were then isolated within the department. National guidance was followed for cancer pathways and complications. We observed a patient who had previously had a kidney transplant being isolated in a room in the department to prevent unnecessary exposure to infection.

Volunteers were available to support patients in the department. There was also an alcohol liaison service for advice and referral.

The service did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services.

Trust processes did not always follow national guidance. For example, emergency department staff retained responsibility for patients even after referral to other specialty. This was not in line with the “Getting It Right First Time” (GIRFT) Clinical Operational Standards (a national NHS England programme designed to improve the treatment and care of patients through in-depth review of services, benchmarking, and presenting a data-driven evidence base to support change). Specialities, other than medicine, such as surgery or orthopaedics, did not always see patients in the emergency department in a timely way. This led to patients waiting longer than expected for a speciality consultation and disposition decision (including admission). This did not follow the recent trust Patient Pact agreement (this pact created referral criteria for emergency department referrals to specialities, to eliminate disputes around specialty acceptance and reduce waiting times in the emergency department).

The teams usually had effective working relationships, including reasonable handovers, with other relevant teams within the organisation (for example, care co-ordinators, discharge teams, and specialist teams). Staff were aware of local and system pressures through Operational Pressures Escalation Levels (OPEL) framework. This was a tool used by NHS organisations to assess capacity and manage demand, ranging from normal level of activity through to extreme pressure/critical incident. However, some specialities did not adhere to the Patient Pact and led to patients waiting longer than expected to be cared for in the most appropriate area of the hospital. There was inconsistent implementation of these Internal Professional Standards (the Patient’s Pact)

Teams worked together to support appropriate care. A range of staff attended meetings and huddles to share information about current situations regarding Infection Prevention and Control processes. For example, whether staff needed to wear masks when in clinical areas. Senior managers attended meetings and promoted actions to increase patient flow across inpatient areas across the hospital.

There were transfer protocols for critically ill children to a specialist Paediatric NHS hospital. Discharge letters were sent to GPs electronically. If a patient wanted a copy, they had to request it.

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.

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure outcomes were positive and consistent, or they met both clinical expectations and the expectations of people themselves.

There was a simple quality management and improvement programme for the emergency department. The latest plan was dated 2024-2025 and included national and departmental issues. For example, sepsis (national issue), ambulatory pathway (local issue) and sustainability (trust objective). However, data showed there was little progress documented for this quality management and improvement programme and limited improvements noted.

The trust monitored performance metrics within the emergency department. Initial patient triage should be conducted within 15 minutes of arrival. The average time from arrival to triage over the 6 months from June to November 2025 was 18 minutes. Over the last 12 months, 55.4% of patients were triaged within 15mins. This was above the Royal College of Emergency Medicines (RCEM) standard of at least 50%. This position was weaker for the first week of December with 41.6% of patients triaged within 15mins. This was also our observation during the assessment. In the Paediatric emergency department, the waiting time was 28 minutes for triage and 2 hours 18 minutes for assessment.

In the last 2 years of data (to August 2025), there has been an increase in the number of patients attending the emergency department. After arriving in emergency department and after triage, patients received the first part of their treatment and average of 69 minutes waiting. This has generally been below regional figures and has been consistently below national figures. Patients have also spent an average time between 3 and 3.5 hours in the department. This includes waiting to be admitted to a ward, transferred to another department, or discharged. However, over this period, there has been a higher number of patients attending the emergency department and leaving before being seen. Since February 2025, this figure has been increasing.

Departmental flow and efficient bed occupancy was challenged across the trust, with the weaker balance at the Gloucester site with an average bed occupancy of 94.7% (86.8% at Cheltenham). The 21+ days length of stay was reasonable compared to national average, at 11.6%. Patients with a “no criteria to reside” was challenged at 19.5%. Elderly care and frail patients faced significant challenge in the emergency department. Data from the Safe and Ambulatory Patient Indexing Tool (SAPIT) part of the “Getting it Right First Time” dataset showed patients aged 70+ spent 10.8 hours in the emergency department. This number was strongly associated with deconditioning of their physical condition. This result was notably poorer than the national average.

In the emergency department, the 12-hour performance was very challenged at 12.4%. Despite improvement in the last 12 months, this was significant compared to the national average. Patients waited over 13 hours for admission. This correlated with delay related harm affecting 191 patients over the last year, the second highest in the Southwest. The Safe and Ambulatory Patient Indexing Tool data set also showed the emergency department census at midnight was higher than at midday. This meant more patients were in the emergency department at midnight than at midday. This was an unusual pattern, strongly associated with crowding and specifically corridor care and high volume admitted caseload in the emergency department.

The department had a dashboard at the nurse’s station, but this was infrequently used. By utilising the dashboard for the emergency department could help assess level of crowding and inform decision making.

There were some clinical audits carried out within the emergency department, but this did not include management of pain in adults and children.

Staff used recognised tools to improve the detection and response to clinical deterioration in patients as a key element of patient safety and improving patient outcomes. Staff used the National Paediatric Early Warning System for children, and they received developmentally appropriate assessments of their immediate emotional and mental health needs. Nurses conducting triage had received training.

For mental health patients, data showed patients spent an average of 8-9 hours in the emergency department. This compared reasonably to the national average.

The service did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

Trust data showed emergency department nurses, health care assistants and doctors receive training in mental health awareness. The overall total for compliance was 92%. However, medical and dental staff only had a completion rate of 27%. Staff told us, in both children’s and adults emergency departments, they did not receive sufficient mental health training for the role expectations. Staff felt there was a lack of eating disorders specialism and training in the mental health liaison team and acute staff teams. They also felt there had been an increase in presentations and admissions for eating disorders, but this was not on the emergency department risk register.

Staff in the Paediatric ED told us they received training for deprivation of liberty (DoLS), mental capacity and consent and felt confident in this area. However, training for mental capacity and deprivation of liberty did not appear on the trusts’ statutory or mandatory training list.

The service maintained up to date policies and processes regarding the mental capacity act (MCA) 2005 and restrictive practice, including rapid tranquilisation. Staff could access up-to-date policies at any time on the trust’s intranet.

Consent to care and treatment was obtained in line with legislation and guidance, including the MCA and the Children’s Acts 1989 and 2004. People were supported to make decisions and, where appropriate, their mental capacity was assessed and recorded. When people lacked the mental capacity to make decisions, “best interest” decisions were made in accordance with legislation. The use of restraint was understood and monitored, and less restrictive options were used where possible.

Translation services were available to facilitate discussions around consent for patients and clinical staff. Consent was documented in notes or on consent forms, but there were no regular monitoring and audit of this.

There was a chaperone policy for adults and children and as part of the consent process which patients had access to if needed.