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

At our last rated assessment in 2023, we rated this key question as requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk people could be harmed.

Safety was compromised by system capacity failure, which led to sustained ED crowding, prolonged waits and one of the highest delay related harm rates in the region. Non-designated clinical spaces used for patients (corridor care) continued, evidenced by the midnight census exceeding midday levels (this signifies severe patient flow blockages indicating a lack of daytime discharges. This causes the hospital to accumulate an unsustainable overnight backlog before the next day's new admissions). Frail patients were particularly affected by long stays and deconditioning. Corridor care in ED was poorly controlled, with capacity strained ambulance handover processes and inconsistent implementation of Internal Professional Standards (the Patient’s Pact) contributing to delays in speciality review. Time to treatment (from arrival to the first clinician review) underperformed Royal College of Emergency Medicine (RCEM) standards.

The service worked on two systems: paper and the electronic patient record. Paediatric triage was paper based documentation which created workflow risks. As a result, children with abnormal vital signs at triage may have repeat observations and analgesia delayed. Governance activity was variable, and concerns about staff culture further affected the reliability of day-to-day safety mitigations.

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.

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.

Trust policies and procedures provided staff with guidance for reporting, managing, investigating, and learning from incidents. The trust’s incident reporting and management policy was in line with the requirements of the national patient safety incident response framework (PSIRF) and focused on learning from incidents to provide safer care.

Review of incident data showed areas for learning and improvement were identified and action plans written. Incidents were reviewed by governance leads to identify and monitor risks and inform quality improvement projects. Incidents were presented at patient safety review panels and responded to with patient safety incident investigations, multi-professional reviews or quality summits.

There was a culture of safety and learning. Safety events were analysed, investigated, thoroughly, and lessons learned to continually identify and embed good practices. For example, an effective method of recognising patients who were at high risk of falls by trialling yellow patient wrist bands so staff could identify them immediately. However, nursing risk and falls assessments were not always completed and updated regularly so success was limited.

The highest reported incidents from May to October 2025 related to violence and aggression within the department. There was a trust violence and aggression policy. Themes across the trust’s 2 emergency departments for the 18 months prior to our visit showed an increase in incidents of abuse from April (14 incidents) to September 2025 (27) but a decrease from September to December 2025 (8 incidents). Violence and aggression were on the corporate risk register due to the risk of physical or psychological harm to patients, relatives, public and staff during incidents involving abusive, threatening and offensive behaviour or physical violence. Staff had access to support when they experienced traumatic or stressful incidents in the workplace.

Staff received regular feedback and learning updates through weekly emails and daily safety huddles. They reported feeling supported and confident concerns would be met with understanding and not blame. Clinical staff were debriefed and received support after a serious incident. However, this was not extended to non-clinical staff who may have been involved.

Staff at all levels understood and applied the duty of candour following incidents. They were open and transparent and gave patients and families a full explanation when things went wrong.

Staff were aware of the complaints and compliments process and could explain it to patients. Complaints and compliments were managed and investigated within the department by senior management. Learning from, complaints and compliments was shared with staff through weekly emails, daily safety huddles and handovers.

The service did not work well to establish and maintain safe systems of care. They did not manage or monitor people’s safety.

Total attendances to the 2 emergency departments across Gloucestershire Hospitals NHS Foundation Trust remained stable, similar to pre-COVID-19 figures. However, since March 2025, there had been an increase in the total admission rates across all the trust’s emergency services.

After initial triage, patients progressed to the waiting area to be seen by a doctor. In the 2nd adult waiting area, staff called patients in for review and treatment. However, patients could wait up to 5 hours or longer to be seen. This area was particularly crowded with more than 80 patients waiting on the day of assessment. There were not enough chairs, trolleys or beds to accommodate everyone, with patients and relatives sat on the floor. There was very limited clinical oversight of this crowded area. This meant patients could deteriorate without being noticed. This was a known risk for the department and was on the trust risk register. There was a dashboard in at the nurse’s station to help assess level of crowding and inform decision making but this was infrequently used. This risk was on the corporate risk register but there was no mitigating actions noted.

Most staff we spoke with were not aware of NHS guidance or any hospital guidance for caring for patients in non-designated clinical spaces for patient care or ‘corridor care’. NHS England guidance states vulnerable groups should not be admitted to non-designated clinical spaces. This included individuals who were severely frail or at end of life, patients with mental health needs, learning disabilities, neurodivergence or autism, patients suffering from dementia, confusion or delirium and patients who were confirmed or suspected infections. Due to lack of guidance, there was no assurance those patients were excluded from corridor care, although staff worked hard to ensure patients with an infection had a side room. On assessment, we found between 7 and 11 patients each day being cared for in corridors and spaces inappropriate for clinical care. None of the patients, at the time, appeared to be in the vulnerable group.

The Trust Escalation and Flow policy stated, ‘Corridor care will not be supported by the trust.’ However, increased attendances in the emergency department and bed closures for remedial work on wards had increased corridor care in the emergency department . Since the assessment, the trust has drafted an ‘Emergency Department — Corridor Care Escalation’ standard operating procedure to ensure safe care was provided in these circumstances and was still in draft form following the assessment.

Staff assessed patient acuity when they arrived by ambulance. However, patients were not always cared for in designated clinical spaces due to increased service demand and delays to ward admission. Initial assessment of patients should be within 15 minutes from arrival in line with the NHS Constitutional Standards, but this was often delayed due to lack of capacity/space within the department.

The ambulatory patient pathway began at reception where basic details were taken. There was a streaming nurse from 10am – 11pm to direct patients to a more appropriate service rather than the emergency department. This included community Minor Injury Unit, Same-Day Emergency Care (at Cheltenham General Hospital or Gloucestershire Royal Hospital), Out-of-Hours GP or directed to return to an outpatient clinic later. The initial patient triage should be conducted within 15 minutes of arrival. The average time from arrival to triage between June and November 2025 was 18 minutes. In the Paediatric emergency department, the waiting time was 28 minutes for triage and 2 hours 18 minutes for assessment. Nurses conducting triage had received training for this.

There was concurrent triage by emergency department staff and the Mental Health Liaison team. Content of triage was sufficient including, risk, physical health needs, substance use, consent, and capacity. There were additional screening questions for children under 18 which was safeguarding focused.

Sepsis was identified and managed through the use of the National Early Warning Score 2 (NEWS 2) and National Institute for Health and Care Excellence (NICE) guidance. In August, September and October 2025, an average of 50% of patients received a NEWS2 assessment in less than 15 minutes of triage. Data showed 4 out of 5 patients with a NEWS2 score of 5 or above (medium risk requiring an urgent review by a clinician) were escalated in accordance with the escalation policy. However, this did not include the administration of antibiotics as the NICE guideline 53 stated, “Give people aged 16 or over who are at high risk of severe illness or death from sepsis, broad-spectrum intravenous antibiotic treatment, within 1 hour of calculating the person's NEWS2 score on initial assessment in the emergency department …”. A quality improvement project was undertaken in the emergency department to reduce the average time to antibiotic administration in high-risk septic patients by 20 minutes. Pre-project time to antibiotics from time of triage within the emergency department was 91 minutes. Post-project time to antibiotics was 84 minutes, a reduction of 7 minutes. The next cycle of the project was the use of sepsis trolleys in the rapid access and treatment area. It was planned the trolley should consist of a locked medication drawer to allow medicines for treatment of sepsis with intravenous antibiotics, intravenous fluids and blood sampling equipment available immediately. However, there was no planned timescale for this at present.

Staff were not always aware of specific risk issues, such as falls or pressure ulcers and did not always planned care for these accordingly. We found nursing risk and falls assessments were not always completed and updated regularly. We found several patients who had not had any risk assessments completed despite being in the department for a long time. The trust conducted 4 documentation audits of the emergency department safety checklist from June – December 2025 which showed an inadequate level of documentation. In September 2025, of the 18 patient notes audited, none had had a pressure ulcer risk or infection control risk completed and only 1 patient had a falls risk assessment. Learning using the yellow wristband for patients at high risk of falls only worked when patients had a falls risk assessment, therefore success was limited.

The number of patients nursed in corridor areas prevented adequate skin checks and some patients with a community acquired pressure ulcer which, due to long hours of delay to have skin assessment, could have led to being categorised as hospital acquired. A subsequent action plan, as part of the pressure ulcer prevention strategy, noted corridor care as a contributory factor. Actions included a quality improvement project workshop on the completion of the emergency department safety checklist.

The service’s referral and admission processes usually ensured information about the patient was received to determine if the patient’s needs could safely be met. Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge.

Patient information was shared with health and social care partners. This included 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 work in partnership with the emergency department. Their purpose was to identify patients who could be treated at home but needed additional support which they would provide.

There were safety huddles, operational bed meetings and handovers staff attended throughout the day. Handovers were led by clinical staff for each area within the emergency department. However, it was unclear which handover the nurse in charge attended to have the overall picture of the department. The nurse in charge of the emergency department linked with bed managers at the daily bed management site meetings.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve it. 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. The service shared concerns quickly and appropriately.

Staff were trained in safeguarding at the correct level for their role, knew how to make a safeguarding alert, and did, when appropriate. Staff gave examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies.

Staff followed safe procedures for children visiting the service. There was a lead consultant and lead nurse for safeguarding within the Paediatric ED. Staff could access support with paediatric safeguarding concerns 24 hours a day. Staff knew who the safeguarding lead was and how to access the safeguarding policy.

The service did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People did not receive consistent support from staff to manage risks associated with their health and wellbeing. This was because there was a lack of written guidance for staff and staff were not always knowledgeable about risks, including caring for patients in the corridor. Also, the amount of crowding in the department and lack of clinical oversight of the waiting area meant not all patients had safe care. However, staff communicated with patients, so they understood their care and treatment. Patient feedback was very positive.

The service did not always detect and control potential risks in the care environment. They did not make sure equipment, facilities and technology supported the delivery of safe care.

The environment was not always safe and suited to patient needs, including protection from physical and psychological harm due to the volume of patients and relatives in the department.

The minor’s area was crowded, and we found patients being treated in non-designated areas such as corridors and an alcove. The ‘fit to sit’ area in minors accommodated 4 or 5 patients at a time but did not offer privacy for patients in there especially during discussions with emergency department staff. Emergency equipment (portable oxygen and suction, resuscitation trolley) was available and deliverable for patients cared for in these spaces.

Staff were able to summon help quickly in case of patient deterioration or emergencies and patients could be moved between areas in an emergency. However, this was impacted by crowding in the department. While there was limited space to get emergency equipment and staff around a patient in an emergency, this could not ensure privacy and dignity for them and those near them. Patients in designated areas could raise alarm/call for assistance but those cared for in non-designated areas had to catch the attention of passing staff.

Patients in non-designated clinical spaces were sometimes risk assessed including falls, but these were not consistently completed for every patient. It was difficult for staff to maintain infection prevention and control measures in non-designated clinical spaces for patient care. This was because patients could not be isolated if no rooms were available if required.

There was not a private area for staff handovers to protect patient confidentiality within the minor’s area of the department. We observed handover at the nurse’s station in minors and patients and relatives could clearly hear what was said as it was very busy. A patient waiting to speak to a nurse for 5 minutes overheard the handover.

Within the paediatric area the equipment was within service date. There was a quiet room with soft seating and no ligature points seen. The clean utility room had a high handle but was not locked. We found 1 cupboard was unlocked and contained 3 different solutions which were out of date. We brought this to the attention of the nurse in charge who took remedial action.

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care met people’s individual needs.

Managers calculated the number and grade of staff required for both emergency departments in Gloucester and Cheltenham with some staff rotating between the 2 units.

Both emergency departments currently had a combined overall vacancy rate of 16.1% which equates to 59.45 whole time equivalent (WTE) vacancies across all levels of staff. The highest vacancy rate was for Medical and Dental staff at 28% and Nursing and Midwifery Registered 13.6%.

The national average for NHS staff turnover in NHS trusts (September 2024) was between 10-12%; The emergency department had a turnover rate of 6.55%. The current national figure for sickness absence within the NHS was 5.3% (February 2025). In the emergency department, the data showed (November 2025) a sickness absence rate of 4% (this was across both emergency departments).

When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. The emergency department was one of the top 3 highest users of bank and locum staff at the trust. Bank and agency staff usage were not reducing to meet trust targets for the year. This was more problematic with medical than nursing staff.

The Paediatric emergency department had dedicated nursing staff. However, due a national shortage of paediatric trained nurses, this impacted the ability to meet demand within the Paediatric emergency department. The trust used a dedicated cohort of adult trained nurses who had additional training to be competent working in children’s ED. This was a planned and reasonable staffing solution to maintain safe service provision, providing a reasonable mitigation to a challenging problem nationally

The emergency department had 18 whole time equivalent consultants which was in line with consultant staffing, between regional and the national average. Consultant recruitment was not an issue. The main difficulty was resident doctors and nurse staffing, especially at night. The present rota allowed for 2 senior residents doctors overnight and consultants could act down to fill gaps on the roster. There should also be 6 junior resident doctors, although this could vary depending on locum availability; there was a high locum burden in the emergency department. However, there tended to be regular locums which promoted consistency. The quality of locums was managed and overseen through a locum lead in the emergency department who supported development and appraisals.

Most staff had received and were up to date with mandatory training including learning disability and autism training. Staff appraisal rate was 77% across both emergency departments. The overall trust compliance for mandatory training rate was 86%. However, the level of mandatory training for medical staff was poor. The compliance rate for Mental Health Awareness was 27%, Fire Safety 67%, Infection Prevention and Control 61%, Information Governance and Data Security 67%, Resuscitation Level 2 Adult Basic Life Support 63% Safeguarding Adults Level 3 40%, all below an acceptable level. No figures for paediatric safeguarding training were submitted for doctors and nursing staff.

Staff received support to deliver safe care. The department had resuscitation practitioners, band 7 nurses with a specific enhanced scope to provide care in the resuscitation area and one for the rapid assessment area. A practice development nurse also supported staff by working with them individually.

There was not always a named clinical lead with oversight and responsibility for all patients in non-designated clinical spaces. There was no staff-to-patient ratio standard in ‘corridor care’ spaces and the ‘Emergency Department Corridor Care Escalation’ standard operating procedure to ensure safe care was given in these circumstances, was still in draft form.

There was a tutor in the emergency department for resident doctor training and an education fellow (post-residency training period where a qualified physician sub-specialises in a specific clinical area). Opportunities for education included formal training on Wednesdays, planned observational assessments, weekly simulation of an event and dedicated sessions for senior residents to support juniors with Workplace-Based Assessments. The provider invested in good training for resident doctors. Doctors were supported with requirements for Certificate of Eligibility for Specialist Registration (CESR). This included consultants in the team who joined through this pathway. The programme was small but included secondments to allow for experience. However, mandatory training figures for medical staff remained poor which has not improved since the last report.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Since the last rated assessment in 2023, improvements have been made with infection control training. Overall, compliance had improved to 84% however, medical staff only achieved 61%.

We found staff did not always adhere to infection control principles, including handwashing. Departmental hand hygiene audits for August to October 2025 were 100% and November 2025 was 90%. However, we observed during the assessment, various grades of staff not washing their hands between patients.

The uniform policy was audited on annual basis as part of the ward/department accreditation process. In November 2025, the uniform audit showed no issues in the emergency department. However, during our assessment, we found staff were not always bare below the elbow, wearing incorrect uniforms, jewellery, false nails and nail polish. There is evidence to indicate false nails, jewellery and watches can harbour micro-organisms and make hand hygiene more difficult. We brought this to the attention of the senior nurse as this was not in keeping with the trust’s uniform or infection prevention policy.

Staff usually maintained equipment well and kept it clean. However, we some found equipment, such as commodes, did not have ‘clean’ stickers on them. It was unclear which commodes were clean and ready for patient use.

The different departments within the emergency department had the necessary furnishings. However, due to the number of patients attending, there were often not enough chairs, trolleys or beds to accommodate all the patients. Although the department was clean, it was very cluttered with equipment and patients struggling for space. This meant the patients could be exposed to infection risks.

Cleaning records were up to date and demonstrated the department areas were cleaned regularly. Cleaning audits for the emergency department (including Children’s ED) showed compliance between 90-100% and there were visible cleaning schedules. There were adequate supplies of personal protective equipment available throughout the department. Staff audited 10 mattresses and cushions a month within the department from different areas. If a mattress or cushion did not meet the standard, they were replaced.

The service did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

The service had systems for the safe handling of medicines. However, these were not always consistently followed by staff.

The emergency department was supported by pharmacy staff to assist with the safe use of medicines. Staff prioritised medicine reconciliation (the process of accurately listing a person’s current medicines) for patients with time-critical or high-risk medicines identified on the electronic prescribing and medicines administration system. However, patients were not always reviewed by pharmacy staff in a timely manner. This was due to the level of clinical pharmacy support available to the emergency department was not in line with national guidance and there was a lack of back-fill for the clinical pharmacy service to the emergency department if staff were absent.

The trust could not be assured medicines and equipment were suitable for use in an emergency. Medicines 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.

The trust could not be assured medicines, including vaccines, were stored according to the manufacturer’s recommendation and suitable for use. A new electronic system was recently introduced for staff to record temperature readings in areas where medicines were stored. We saw this new system was not embedded and daily checks for both room and ambient temperature monitoring had been missed on multiple occasions.

There were processes to improve people’s access to medicines and expedite discharge to improve patient flow within the department. For example, trained staff used Patient Group Directions (PGDs) to provide patients with the medicines they needed. However, we saw some of these printed Patient Group Directions were out of date and required review.

Medicines for use in an emergency and antidotes were available in the department and staff knew how to access these.

We saw various examples of service improvements in relation to medicines use in the emergency department. The pharmacy team were currently working on a national project related to time critical medicines. Other medicines related changes to practice had been made in the emergency department. For example, changes had been made because of a recent medicines alert from the Medicines and Healthcare Regulatory Authority (MHRA) in relation to fluoroquinolones (this was a reminder for prescribing healthcare practitioners to the risk of disabling and potentially long-lasting or irreversible side effects of this medicine).

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

There was a cycle of medicines related audits. Results were used to support improvement work in medicines optimisation. Work from these audits was presented at directorate meetings for discussion.