Gloucestershire Royal Hospital

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

At our last assessment we rated well led as good. At this assessment the rating has declined to requires improvement.

Governance processes were not always effective. Long waits for speciality reviews were not consistently escalated or mitigated, audit programmes were incomplete, and key risks such as crowding in minors and the use of non-designated clinical spaces were longstanding or not reflected on risk registers. Despite these shortfalls, partnership working was strong, and leaders recognised areas requiring further improvement.

Leaders created a positive and improving culture with a clear vision and shared purpose, supported by increased senior presence, strong role modelling and good staff engagement. Staff told us they felt supported, valued and able to raise concerns, and Freedom to Speak Up processes were well embedded. Leadership at all levels was knowledgeable, visible and inclusive, and there was evidence of learning from incidents and a commitment to improvement, including simulation training and quality improvement projects.

We have not awarded this service a score for Well-led.

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

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

There was positive feedback from staff and managers regarding culture and implementation of changes within the department. There had been an increase in senior oversight and presence within the department, professional role modelling and increased staffing and support as well as engagement. This had improved the culture though senior staff were aware there was still more to do to embed the change.

There was a good safety culture where events were investigated, and learning was embedded to promote good practice. Staff said raising concerns was encouraged and valued.

The service worked hard to decrease ambulance handover delays. The average wait ambulance handovers improved significantly since January 2025, when it was over an hour. In December 2025, this had decreased to approximately 20 minutes wait. This significant decrease to the average ambulance handover time was discussed at Board level.

Leaders had a shared purpose and strived to deliver and motivate staff to succeed. We met a leadership team who supported each other well. Generally, there were high levels of satisfaction amongst staff, despite the challenges they faced. Staff felt supported by newly appointed leaders within the department and spoke positively about planned improvements.

The trust had a 5-year strategy setting out their future vision, direction and strategic priorities for the years 2025 to 2030. It acknowledged the significant strain on both emergency departments.

One of the strategic aims of quality, safety and delivery was to restore compliance with the 4-hour waiting standard, as part of the trusts’ clinical vision of flow.

Training programmes helped staff feel confident in their roles. Scenarios were held to provide learning opportunities across the hospital and improve communications.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders usually had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told us they felt supported by managers and had opportunities for development. Managers were visible and approachable. Leaders of the service were knowledgeable about the issues and priorities of the service and worked for change and improvement when needed. They recognised where the service needed to be improved and were working to make improvements. They focused on staff wellbeing and ensured a culture promoting good practice, good quality and aspired to give safe care and treatment.

There was a triumvirate leadership structure with clinical and operational leads. There was a strong and committed leadership team in the department. However, the leadership team’s actions had not had effective impact and addressed issues sustainably. They were open, honest and willing to learn and improve.

Senior leaders were aware of the impact the crowded department has had on staff, and this increased stress. There were support services and actions planned to support culture had been implemented. However, leaders acknowledged there was still more to do.

Leaders had effective support and opportunities to develop and maintain their skills. The roles of staff and leaders were clear, and they understood their responsibilities and accountabilities.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The service had a emergency department (FTSU) policy and established emergency department arrangements. Staff were aware of how to raise concerns with emergency department guardians who worked alongside the leadership teams. There was a emergency department poster in a staff room with contact details for staff to raise concerns or ideas for improvement.

Leaders encouraged staff to raise concerns and promoted the value of doing so.

When something went wrong, people received a sincere and timely apology and were told about any actions being taken to prevent the same happening again. We reviewed learning responses which showed Duty of Candour was completed appropriately.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The trust's governance processes did not ensure people were assessed and treated in line with standards of care. Governance activity was variable, and concerns about staff culture further affected the reliability of day-to-day safety mitigations. This included people experiencing long waits for speciality review.

Governance processes did not always escalate and mitigate risks. Staff had identified patients experiencing long waits for speciality reviews which affected the flow of patients through the emergency department. Leaders said there had been actions taken to manage risks for people waiting for speciality reviews in the Patients Pact. However, these actions had limited impact on the service as yet.

The service could not provide assurance practice was consistently aligned with best practice. Audit programmes were not always comprehensive or effective in monitoring safety and quality. There was limited oversight of nursing risk assessments, with gaps in completion and insufficient action taken to address identified issues. Although audits were undertaken to review standards of record keeping, they did not include important areas such as the management of pain in adults and children.

While some action plans were developed, these were not consistently effective. In several cases, audits were either not completed or not followed through with appropriate action, including nursing documentation audits.

Risk was not always managed effectively. The current top risk in emergency department was the risk to patients within the minor’s area due to crowding and staffing. However, this had been on the risk register since 2015. Actions were taken to address this in the past but had not solved the problem. Further works were planned to mitigate this risk but currently had no start or completion date.

The broader risk relating to crowding in minors and staffing was recorded on the risk register. However, the specific use of non-designated clinical spaces/corridor care was not separately described as a distinct risk entry. Also, there was no guidance for staff to manage patients in these areas. The trust acknowledged corridor care was at risk of increasing due to ambulance handover pressures. Senior leaders were visible and involved in managing and de-escalating non-designated clinical spaces for patient care but there were no action plans to address the short, medium, and longer-term risks associated with it. However, guidance was currently being developed.

There was a set agenda of what was discussed at directorate level in governance meetings to ensure essential information, such as learning from incidents and complaints, was shared and discussed. Staff knew about governance processes and contributed to improvement actions. Weekly harm hubs reviewed incidents for harm, themes and improvements. There was a process for escalating concerns to senior management. Information was disseminated to staff for awareness and action using a variety of meetings.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Staff and leaders understood their duty to collaborate and work in partnership with people, other organisations and services, so services work seamlessly for people. They shared information with partners.

Occupational Therapy support for the emergency department was provided by a Community Assessment Team from another NHS trust. 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 need additional support. They could review patients on the electronic patient systems and negotiate with clinicians what care was needed and how it could be provided to avoid an unnecessary admission. For example, administration of intravenous antibiotics at home. They were keen to support patients at end of life to be cared for at home if it was the patient’s choice. The team also helped learning disability and cerebral palsy patients to be cared for in most appropriate place rather than spending too much time in the emergency department. The team conducted up to 10 rapid assessments of patients a day and could prevent up to 7 admissions a day.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

Staff were given the time and support to develop opportunities for improvements and innovation and this led to improvement in care delivery. This was managed through weekly simulation training on a variety of scenarios.

The service provided a list of quality improvement projects currently being undertaken or had been completed. Staff were usually positive about improving services and work had been achieved through the improvement plan. We saw examples of improvements made by the service regarding completion of the emergency department safety checklist. This included management of patients presenting / developing sepsis in the emergency department and clinical vision of flow for patients who present through triage and ambulatory patients who attend by ambulance and categorised priority 2. However, managers recognised there was further work to be done. For example, due to a required area in the emergency department being unavailable because of demand pressures, the project did not have a planned start date.

There were ongoing discussions ongoing with paediatric consultants regarding the commencement of Paediatrics Early Warning Score (PEWS) audits in line with guidance from Royal College of Paediatrics and Child Health (RCPCH).