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Provider: Gloucestershire Hospitals NHS Foundation Trust Good

On 07 January 2019, we published a report on how well Gloucestershire Hospitals NHS Foundation Trust uses its resources. The ratings from this report are:

  • Use of resources: Requires Improvement
  • Combined rating: Good

Read more about use of resources ratings

Inspection Summary


Overall summary & rating

Good

Updated 7 February 2019

Our rating of the trust improved. We rated it as good because:

Safe, effective, caring and well led were rated as good, however responsive remains requires improvement. We rated eight of the trust’s 18 services, across two of its three sites. Our inspection of the core services covered both Gloucestershire Royal Hospital and Cheltenham General Hospital. We did not inspect Stroud Maternity Hospital. In rating the trust, we took into account the current ratings of the ten services not inspected this time.

We rated well-led for the trust overall as good.

  • Urgent and emergency care was previously rated as requires improvement at both Gloucestershire Royal Hospital and Cheltenham General Hospital and had improved since the last inspection. The domain of Safe has improved at Gloucestershire Royal Hospital making them good overall. The domains of safe and responsive at Cheltenham General Hospital have improved making the service good overall. We found that staff had received up to date mandatory training and safeguarding training to protect patients from harm or abuse. Staff managed risks well for each patient. Staff were working based on best practice and evidence. There were audits to support performance. We found that staff managed pain well and nutritional and hydration need were met. Staff were compassionate and caring towards patients. Access to services required improvement at Gloucestershire Royal Hospital as some targets were not met. At Cheltenham General Hospital four hour targets and ambulance handover targets were consistently met month on month. At both sites we found the service had identified risks to high quality care.
  • Medical care (including older people’s care) was rated as good at both sites and had gone up one rating since its last inspection. On both sites safety was rated as good, which was an improvement since the last inspection. We found that there were good levels of mandatory training and that staff recognised abuse and knew how to report it. Staffing levels had improved and the service managed safety incidents well. The service delivered care and treatment in line with evidence-based practice, and managed nutrition and hydration well. Managers monitored the effectiveness of care and treatment and used their findings to improve them. Staff cared for patients with compassion. On both sites well led was rated as good, which was an improvement since the last inspection. Managers at all levels in the service had the right skills and abilities to run a service and strived to provide a good service and had a systematic approach to continually improve the quality of its services. The service was committed to improving services by learning from when things went wrong, promoting training, research and innovation.
  • Surgery was rated as good at both sites and had gone up one rating since the last inspection. Safe had improved, staff completed and updated risk assessments for each patient, and there were processes to recognise and respond to a deteriorating patient. The World Health Organisation (WHO) surgical safety checklist was used in theatres and observations showed they were performed well and staff were engaged with the process. Effective stayed the same and was rated as good, treatment was based on national guidance and evidence of its effectiveness, and the trust generally performed well compared nationally when we reviewed data for audits. We found all staff provided excellent care to patients at both sites and rated caring as good. Responsive was requires improvement as waiting times for referral to treatment was delayed and not in line with good practice for some specialties, and improvement was required to promote flow and efficiency in theatres. Well-led was rated as good, the surgical division had strengthened its leadership with a new team. There were quality improvement projects which were key in proactively engaging and involving staff and patients, and to shape and improve services.
  • Outpatient services were rated as good. We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings. The service managed infection risk well. The service had suitable premises and equipment and looked after them well. Staff could identify and respond to a deteriorating patient within the outpatient environment, including medical emergencies. Staff kept appropriate records of patients’ care and treatment. Patients were treated with compassion, kindness, dignity and respect. The trust had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. Leaders had the experience and skills to ensure that improving outpatient services were being delivered. The trust had produced a “Transformation Plan” for the outpatient’s service in July 2018 aligned to the trust overall strategy of being on a “journey to outstanding”. Managers across the trust promoted a positive culture that supported and valued staff. The transformation plan for the outpatient’s service contained a number of ideas for the improved delivery of service.

Inspection areas

Safe

Good

Updated 7 February 2019

Our rating of safe improved. We rated it as good because:

  • We rated safety in urgent and emergency care at Gloucestershire Royal Hospital and Cheltenham General Hospital as good. This was because staff had received up to date mandatory training and safeguarding training to protect patients from harm or abuse. Staff managed risks well for each patient. Staff kept detailed records of patients’ care and treatment. The service managed safety incidents well and used safety monitoring results well. The emergency department at Cheltenham General Hospital mostly prescribed, gave, recorded and stored medicines well. However, we found a high vacancy rate, but this was mitigated through good use of bank and agency staff.
  • We rated safety in medicine at both Gloucestershire Royal Hospital and Cheltenham General Hospital as good. This was because most staff were compliant with their mandatory training updates. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The staffing levels had improved and the service managed patient safety incidents and used safety monitoring results well. However, the service did not control some infection risks consistently and staff did not always take appropriate actions when they identified deteriorating patients. At Cheltenham General Hospital staff did not always follow best practice when storing some medicines.
  • We rated safety in surgery at both Gloucestershire Royal Hospital and Cheltenham General Hospital as good. This was because staff understood their responsibilities to protect patients from abuse and we found that standards of cleanliness minimised infection control risk. Staff could recognise a deteriorating patient and we found that surgical safety checklists were used effectively. The trust had reviewed their safety culture and human factors, and could demonstrate learning and improvements following never events. However, there were signs of wear and tear and some wards and theatres were cluttered. Medical gas oxygen cylinders were not being stored securely across wards and theatres. Staffing on wards was regularly at minimum staffing levels rather than at funded establishment.
  • We rated safety in outpatients at Gloucestershire Royal Hospital as good. This was because staff were confident in identifying and responding to a deteriorating patient. Staff recognised safety incidents and reported them appropriately. Equipment was in good working order and clinical waste was managed well. However, the environment in Cheltenham General Hospital did not promote good infection control practices.

Effective

Good

Updated 7 February 2019

Our rating of effective improved. We rated it as good because:

  • We rated effective in urgent and emergency care at Gloucestershire Royal Hospital and Cheltenham General Hospital as good. We found care and treatment was provided in line with best practice and evidence-based guidance which was supported by audits. Staff mostly assessed and monitor patients to see if they were in pain. Staff gave patients enough food and drink to meet their needs. The emergency department met the NHS England standards for seven-day service provision and staff understood how and when to assess whether a patient had the capacity to make decisions about their care. The service monitored the effectiveness of care and treatment and used the findings to improve them. Staff mostly had access to up-to-date, accurate and comprehensive information on patients’ care and treatment. Staff understood how and when to assess whether a patient had the capacity to make decisions about their care.
  • We rated effective in medicine at both Gloucestershire Royal Hospital and Cheltenham General Hospital as good. This was because the service provided care and treatment based on national guidance and nutrition and hydration met the needs of patient to improve their health. Staff with different skills and experience worked well together and staff were consistent in their approach to supporting people to live healthier lives. However, performance in national audits was variable and staff did not always complete malnutrition screening assessments consistently.
  • We rated effective in surgery at both Gloucestershire Royal Hospital and Cheltenham General Hospital as good. Care and treatment was based on national guidance and the trust could evidence its effectiveness. Assessments for pain and nutrition were used to improve patient care. Staff of different disciplines and roles worked together as a team to benefit patients. The surgical service made sure staff were competent in their roles. However, staff demonstrated a limited understanding of the Mental Capacity Act. Deprivation of liberty safeguards applications did not adequately describe the treatment proposed or restrictions to be placed upon somebody and Compliance with the seven-day standards was not always consistent. At Cheltenham General Hospital there was still no formal out of hours interventional radiology rota for vascular, urology and gastro intestinal services.
  • We did not rate effective in outpatients at Gloucestershire Royal Hospital or Cheltenham General Hospital. The physical, mental, and social needs of patients were holistically assessed. Patients who were in the departments for any length of time had access to food and drink sufficient to meet their needs. There was professional multi-disciplinary working throughout the outpatient’s department. Staff worked together as a team to benefit patients. Outpatient services were primarily a five-day service. Whilst there were some early evening and occasional clinics being run on Saturday mornings.

Caring

Good

Updated 7 February 2019

Our rating of caring stayed the same. We rated it as good because:

  • We rated caring in urgent and emergency care at Gloucestershire Royal Hospital and Cheltenham General Hospital as good. Staff provided compassionate care to patients and were able to support them emotionally. We saw good examples of staff involving carers in decisions. Feedback from patients confirmed that staff treated them well and with kindness.
  • We rated caring in medicine at Gloucestershire Royal Hospital and Cheltenham General Hospital as good. This was because staff cared for patients with compassion and staff provided emotional support to patients and families to minimise their distress. Staff also involved patients and those close to them in decisions about their care and treatment.
  • We rated caring in surgery at both Gloucestershire Royal Hospital and Cheltenham General Hospital as good. This was because all staff were committed to providing excellent care to their patients. Staff provided emotional support to patients to minimise their distress and staff involved patients and those close to them in decisions about their care and treatment. In Gloucestershire Royal Hospital therapy staff engaged patients in activities and provided compassionate care. However, it was not clear what emotional support was available for patients who had received amputations, or how they were supported to access further services.

  • We rated caring in outpatients at both Gloucestershire Royal Hospital and Cheltenham General Hospital as good. This was because patients were treated with compassion, kindness, dignity and respect. Staff provided emotional support to patients to minimise their distress and we saw patients having treatments explained and discussed, and the options that were available.

Responsive

Requires improvement

Updated 7 February 2019

Our rating of responsive stayed the same. We rated it as requires improvement because:

  • We rated responsive in urgent and emergency care at Gloucestershire Royal Hospital as requires improvement and Cheltenham General Hospital as good. At Cheltenham General Hospital we found that the four-hour target was consistently met and performed better than other trusts. Although targets were not met at Gloucestershire Royal Hospital, we saw vast improvement in pathways and streaming of patients since the last inspection. Both sites treated concerns and complaints seriously, investigated them, learned lessons from the results, and shared these with all staff. However, tools to improve care for vulnerable patients were not consistently used.
  • We rated responsive in medicine at Gloucestershire Royal Hospital and Cheltenham General Hospital as requires improvement. This was because people could not always access services in a timely way. Waiting times from referral to treatment times failed to meet national targets and the trust data was not being reliably reported.
  • We rated responsive in surgery at Gloucestershire Royal Hospital and Cheltenham General Hospital as requires improvement. This was because patients were not always able to access the service when they needed it. The trust was unable to deliver reporting on national waiting time standards. Performance of urology and general surgery, for patients waiting over 18 weeks from referral to treatment, was below the England average. The day surgery unit at Gloucestershire Royal Hospital was still not a suitable environment, however there were plans to improve the environment. The signage across both hospital sites did not help patients access and find services easily. However, the surgical service was reviewing and making changes to the way they delivered services across the two hospital sites. The flow through the hospital was now being monitored, evaluated and prioritised, with a focus on patient safety and quality improvement projects had helped to improve the service being delivered to patients.
  • We rated responsive in outpatients at both Gloucestershire Royal Hospital and Cheltenham General Hospital as requires improvement. This was because Patients could not always access services when they needed them. The introduction of a new patient appointment booking system, had presented a number of difficulties in the delivery of services. There had been large increases in waiting times and a build-up of delayed clinic letters that needed to be sent out. However, the trust had a recovery programme, to address all the identified issues around data quality and the patient appointment issues. The service took account of patients’ individual needs and considered different needs and preferences. Clinics generally started on time and patients were promptly informed of delays. At the time of the inspection the trust had recorded in total a 36% reduction in the number of complaints recorded from the previous year’s 2017/18 total.

Well-led

Good

Updated 7 February 2019

Our rating of well-led stayed the same. We rated it as good because:

  • We rated well led in urgent and emergency care at Gloucestershire Royal Hospital and Cheltenham General Hospital as good. This was because we found Leaders at both sites promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. There was a systematic approach to continually improving the quality of its services and safeguarding high standards of care, by creating an environment in which excellence in clinical care would flourish. The department collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards. There was a holistic understanding of departmental performance. Data was used to lead discussions about quality, operations and finances and there were effective systems for the collection, display and analysis of information to support the delivery of good care.
  • We rated well led in medicine at both Gloucestershire Royal Hospital and Cheltenham General Hospital as good. This was because managers at all levels in the service had the right skills and abilities to run a service and strived to provide a good service. The service used a systematic approach to continually improve the quality of its services and the service collected, analysed, managed and used most information well. However, not all risks we identified during the inspection were recognised and mitigated by the service.
  • We rated well led in surgery at both Gloucestershire Royal Hospital and Cheltenham General Hospital as good. This was because there was a new leadership team in many areas of the surgical division, and trust wide, to strengthen surgical leadership. They were knowledgeable about quality issues and priorities. The surgical division had a vision for what it wanted to achieve and workable plans to turn it into action. Overall, there was an optimistic culture within the surgical division. Quality improvement projects were key in proactively engaging and involving staff and patients, to shape and improve services. However, there were no review dates for risk registers, or a clear trail of dates of added and reviewed risks. The information used in reporting, performance management and delivery quality care were not always accurate, valid and reliable.
  • We rated well led in outpatients at both Gloucestershire Royal Hospital and Cheltenham General Hospital as good. This was because the trust had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. Nursing staff, healthcare staff, managers and reception and administration staff were positive about the support from their line managers. The trust had produced a “Transformation Plan” for the outpatient’s service in July 2018 aligned to the trust overall strategy of being on a “journey to outstanding” and There were appropriate levels and structures of governance across outpatient services to ensure safety was monitored and improvements supported.