Gloucestershire Royal Hospital - Care Quality Commission

This report describes our judgement of the quality of care at this hospital. It is based on a combination of what we foundwhen we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from patients, thepublic and other organisations.

Ratings

Urgent and emergency services Requires improvement –––

Medical care (including older people’s care) Requires improvement –––

SurgeryMaternity and gynaecologyServices for children and young people

End of life care Good –––

Outpatients and diagnostic imaging

Gloucestershire Hospitals NHS Foundation Trust

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Gloucestershire Royal HospitalGreat Western RoadGloucesterGloucestershireGL13NNTel: 0300 422 2222Website: www.gloshospitals.nhs.uk

Date of inspection visit: 24-27/01/2017, 06/02/2017Date of publication: 05/07/2017

1 Gloucestershire Royal Hospital Quality Report 05/07/2017

Letter from the Chief Inspector of Hospitals

We carried out an announced inspection 24-27 January 2017 and an unannounced inspection at Gloucestershire Royalon 6 February 2017. This was a focused inspection to follow-up on concerns from a previous inspection. As such, not alldomains were inspected in all core services.

The inspection team inspected the following seven core services at Gloucestershire Royal Hospital:

• Urgent and emergency services

• Medical care (including older people’s care)

• Surgery

• Maternity and gynaecology

• Services for children’s and young people

• End of life care

• Outpatients and diagnostic imaging

We did not inspect the critical care services (previously rated outstanding).

As we did not inspect all services we did not rate Gloucestershire Royal Hospital at this inspection.

Safe

We rated the safe domain as requires improvement in urgent and emergency services, medicine, surgery, maternity andgynaecology and also outpatients and diagnostic imaging. We rated it as good in children’s and young peoples and endof life services.

• We had concerns about patient safety, particularly when the emergency department was crowded. Lack of patientflow within the hospital and in the wider community created a bottle neck in the emergency department, creatingpressures in terms of space and staff capacity. This in turn increased the risk that patients may not be promptlyassessed, diagnosed and treated.

• Crowding was compounded by an acute shortage of staff. There was an acute shortage of middle grade doctors andthere were particular concerns raised by medical and nursing staff about medical cover at night. Consultantsregularly worked longer hours to support their junior colleagues and there were concerns about whether this couldbe sustained. Analysis of demand patterns indicated that more senior decision-makers were required at night. Thedepartment was not fully staffed with nurses. There were a significant number of nurse vacancies and heavy relianceon bank and agency staff to fill gaps in the rota. The department was not consistently staffed to planned levels, andwhen the department was crowded staff felt vulnerable because planned safe staff to patient ratios could not bemaintained.

• There was no senior (band seven) nurse employed to manage each shift as recommended by the National Institutefor Health and Care Excellence (NICE).

• Support staff functions were not adequately resourced. Healthcare assistants performed housekeeping duties,doctors, nurses and managers moved patients, and the nurse coordinator was frequently occupied withadministrative duties.

• Crowding in the emergency department meant that ambulance crews were frequently delayed in handing over theirpatients.

Summary of findings


• Patients were not always assessed quickly on their arrival in the emergency department. Initial assessment (triage)often consisted of a verbal handover from ambulance staff to the nurse coordinator without a face to faceassessment of the patient.

• Record keeping was generally poor and we could not be assured that patients received prompt and appropriateassessment, care and treatment. In particular, we were concerned about the recording of observations and thecalculation of early warning scores. Patient observations were not always carried out consistently or early enoughand early warning scores were not consistently calculated.

• The mental health assessment room did not comply with safety standards recommended by the Royal College ofPsychiatrists.

• Within the medical service, not all specialties held regular and structured mortality and morbidity meetings to ensurelearning could be identified and shared.

• Staff did not always follow infection control procedures when entering wards and ensuring the cleanliness ofequipment such as commodes.

• Wards did not display evidence of when areas such as toilets were last cleaned and we did not see environmentalaudit result displayed on the wards we visited.

• Staff did not always comply with legislation regarding the Control of Substances Hazardous to Health (COSHH).• The fabric of the building did not always ensure efficient cleaning could be carried out.• Daily checking of equipment such as resuscitation equipment was not carried out in all areas in line with the trust’s

policy.• Medicines were not always managed correctly. Fridge temperatures were not monitored or actions taken where

these fell out of normal range. There were a number of out of date patient group directives (PGD’s) in use in maternityservices.

• Records were not stored safely to ensure patient confidentiality was maintained at all times.• Staff did not always assess risks to patients and follow up with mitigating care interventions.• Nursing staffing levels were below establishment and wards, departments and operating theatres relied on bank and

agency to cover shifts every day.• The trust did not use a recognised tool to assess the acuity of patients daily to ensure safe staffing levels were in

place on each shift and particularly at night.• The number of surgical site infection rates for replacement hips and knees and spinal surgery had increased since

our last inspection.• Mandatory training for all staff was not meeting the trust’s target.• The day unit was being used as an inpatient ward but domestic cover had not been set up for weekends to provide

environmental cleaning or drinks to patients.• There was no cleaning carried out over the weekend in diagnostic imaging, and some outpatient treatment rooms

and waiting areas were visibly dirty.• Staff were finding it difficult to trace patient notes since the introduction of a new computer system, and there was

not a reliable system to track the numbers of temporary notes being used since its implementation. There were alsosome ongoing issues with allocation of baby NHS numbers and records migrating to the new system.

• Some staff were unsure of their responsibilities in a resuscitation situation, and staff in ophthalmology did not knowwhere to locate their nearest defibrillator.

• In some areas, a systematic check of emergency resuscitation trolleys was not documented as having being carriedout on a daily basis. There were no up to date Resuscitation Council (UK) guidelines available on the resuscitationtrolleys. Intravenous fluids on the emergency resuscitation trolleys were not stored securely to ensure they weretamper evident.

• Community midwives could not always print out clinical notes from the electronic system to go into women’shandheld notes. They also reported poor mobile phone coverage which meant there was sometimes a delay ingetting messages.

Summary of findings


• Junior doctors in obstetrics did not attend skills drills training when they started at the trust though they did carry anemergency bleep and co0uld be the first to arrive in the delivery.

• There were often long waiting times in the maternity triage area. Women were not seen within 15 minutes ofattending the unit.

• Consultant presence, on labour suite, was below the recommendations of the Royal College of Obstetricians andGynaecologists (RCOG) Safer Childbirth (2007) guidance.

• Not all outpatient waiting areas in the hospital had specific children’s areas. Areas that were not solely for children’suse in other parts of the hospital had waiting areas that were shared with adults.

However:

• Staff understood their responsibilities to raise concerns and report incidents using the electronic reporting system.There was a culture of shared learning from incidents.

• Staff spoke confidently about the duty of candour and gave examples of where it had been applied. Relevant staffhad received training.

• Most areas we visited were visibly clean and tidy. Staff were seen adhering to the trusts infection control policiesincluding ‘bare below the elbows”.

• There was a robust security system in place within the maternity unit, including locked doors, entry systems a babysecurity tagging system and CCTV.

• There were systems in place for recognising and reporting safeguarding concerns. Staff were confident to raise anymatters of concern and escalate them as appropriate.

• There was good access to mandatory training within the maternity service, including skills drills training day and aone-day maternity update.

• The development of a training package for midwives to enable them to administer flu vaccinations to at risk womenhad meant that a high number of women who would otherwise have not had the flu vaccine had received it.

• The endoscopy unit had safe processes in place to ensure staff decontaminated and sterilised equipment in line withbest practice.

• Within the emergency department, there were hourly board rounds undertaken by senior clinicians in thedepartment. This provided an overview of the department’s activity and provided an opportunity to identify andcommunicate safety concerns to the site and trust management teams. Patient safety checklists had beenintroduced, which provided a series of time-sequenced prompts. There was a well-structured medical staff handoverwhere patients’ management plans and any safety concerns were discussed.

Effective

We rated the effective domain as good in urgent and emergency services, surgery and end of life. We rated it as requiresimprovement in medical care, We did not inspect this domain in maternity and gynaecology or children’s and youngpeople’s services

• People’s care and treatment was mostly planned and delivered in line with current evidence-based guidance andstandards.

• There was a range of recognised protocols and pathways in place and compliance with pathways and standards wasfrequently monitored through participation in national audits. Performance in national audits was mostly in line withother trusts nationally. There was evidence that audit was used to improve performance.

• Within the emergency department, nursing and medical staff received regular teaching and clinical supervision. Staffwere encouraged and supported to develop areas of interest in order to develop professionally and progress in theircareers.

• Care was delivered in a coordinated and multidisciplinary way.

Summary of findings


• The trust had been identified as a ‘mortality outlier’ in to relation reduction of fracture of bone (Upper/Lower limb)’procedures, which included fractured hip. However, the actions had implemented had made improvements andthese were ongoing at the time of our inspection.

• Staff understood that end of life care could cover an extended period for example in the last year of life or patientsand that patients benefited from early discussions and care planning.

• End of life care was delivered with the principles of the Priorities for Care of the Dying Person set out by theLeadership Alliance for the Care of Dying Patient’s

• Within end of life care, medicines to relieve pain and other symptoms were available at all times. Wards hadadequate supplies of syringe drivers (devices for delivering medicines continuously under the skin) and themedicines to be used with them.

However:

• Pain was not always promptly assessed and managed within the emergency department and we could not beassured that patients’ nutrition and hydration needs were consistently assessed or met.

• The trust was not meeting the standard which requires the percentage of patients re-attending (unplanned) thedepartment within seven days to be less than 5%.

• The new computer system was causing issues for staff resulting in 'work around' processes to prevent any risks topatients.

• Staff appraisals were not meeting the trust targets in all areas.• Theatre utilisation figures were low however; the trust was looking at ways of improving this.• Documentation relating to patients’ mental capacity and consent was not always complete or immediately obvious

in ‘do not attempt cardio-pulmonary resuscitation’ (DNA CPR) records.• Explanations for the reason for the decision to withhold resuscitation attempts were not consistently clear. Records

of resuscitation discussions with patients and their next of kin or of why decisions to withhold resuscitation attemptshad been made were not always documented.

• There was no organisational oversight of staff competency with regards to syringe driver training as records were notheld centrally.

• There was not a seven day face to face service provided by the in-patient and community end of life care team. Thetrust provided a face to face service 9-5 Monday to Friday. Out-of-hours there was a telephone advice line available 24hours, 7 days a week for health care professionals.

• The learning needs of all staff delivering end of life care were not identified.

Caring

We rated the caring domain as good in all the services this domain was inspected (urgent and emergency services,medical care and end of life services).

• All of the patients we spoke with during our inspection commented very positively about the care they received fromstaff. This was consistent with the results of patient satisfaction surveys, which were mostly positive.

• Patients were treated with compassion and kindness. We saw staff providing reassurance when patients wereanxious or confused.

• Patients were treated with courtesy, dignity and respect. We observed staff greeting patients and their relatives andintroducing themselves by name and role.

• Patients and their families were involved as partners in their care. They told us they were kept well informed abouttheir care and treatment. We heard doctors and nurses explaining care and treatment in a sensitive and unhurriedmanner.

• Staff took the time to interact with people who received end of life care and those people close to them in arespectful and considerate manner.

Summary of findings


• Staff and volunteers who worked with the department for spiritual support, bereavement officers and the mortuarywere aware of and respectful of cultural and religious differences in end of life care.

• Emotional support for patients and relatives was available through the in-patient and community specialist palliativecare team, through clinical psychology, social worker, ward-based nurse specialists and end of life champions, thechaplaincy team and bereavement services.

However:

• The discharge lounge was a mixed sex unit and did not have curtains to screen individual chairs and provide privacyfor patients in their pyjamas or when assistance was needed with personal care needs.

• Whilst responses to the friends and family test was positive, response rates were frequently low.

Responsive

We rated the responsive domain as requires improvement in urgent and emergency services, medicine, surgery andoutpatients and diagnostic imaging. We rated it as good in end of life services.

• The emergency department was consistently failing to meet the standard which requires that 95% of patients aredischarged, admitted or transferred within four hours of arrival at the emergency department.

• Patients frequently spent too long in the emergency department because they were waiting for an inpatient bed tobecome available. Lack of patient flow within the hospital and in the wider community created a bottleneck in theemergency department, causing crowding.

• Crowding meant patients frequently queued in the corridor, where they were afforded little comfort or privacy. Whenthe department became congested, relatives had to stand because there was insufficient seating.

• Patients with mental health needs were not always promptly assessed or supported, particularly at night time whenthere was no mental health liaison service. Adolescents who had self-harmed did not receive a responsive serviceand were frequently inappropriately admitted while awaiting specialist assessment and support.

• There was a lack of an appropriate welcoming space for patients with mental health needs.• The delivery of cardiology services did not meet the needs of the local population.• There were delays to discharges, which meant patient flow through the hospital was compromised.• There was a waiting list for patients requiring an endoscopic procedure.• The environment did not meet the needs of patients with dementia.• The trust reported 32 breaches of mixed sex accommodation in the period from January 2016 to October 2016 of

which 11 were in the acute medical admissions unit.• The service was not always compliant with the accessible information standards and information leaflets were not

readily available for patients for whom English was not their first language.• Due to pressure for beds and the demand on services, some patients had to use facilities and premises that were not

always appropriate for inpatients. At times of high operational pressure patients were temporary admitted toendoscopy and medical day unit wards however, these were not identified as ‘escalation areas’ in the inpatientcapacity protocol.

• Elective operations were being cancelled due to the pressure on the beds within the trust and medical patients werebeing cared for on surgical wards to meet the demand.

• Not all patients had their operations re-booked within the 28-day timescale.• Six patients had been waiting over 52 weeks for treatment, which is not acceptable.• The hospital was not meeting the 62 day target for cancer patients.• The diagnostic imaging department had a reporting backlog of 19,500 films and was not meeting its five day

reporting target for accident and emergency x-rays.• A significant typing backlog was causing delays in sending out patient letters impacting on patient safety.• Implementation of new computer systems had impacted on waiting lists as some specialties could not see live

waiting lists.

Summary of findings


• The trust was not meeting referral to treatment target in all specialities.• There were no designated beds for people receiving care at end of life. Side rooms were used when available but

could not be guaranteed.• The percentage of patients dying in their preferred location and the percentage of patients discharged within 24

hours were not all known for all wards or hospital sites.• End of life complaints were not always handled promptly and in accordance with trust policy.

However:

• The emergency and urgent care service had a number of admission avoidance initiatives in place to improve patientflow. These included the integrated discharge team who proactively identified and assessed appropriate patientswho may be able to be supported in the community rather than admitted to the hospital.

• We saw evidence that complaints were used to drive improvement.• The emergency department had recently developed a team known as the Gloucestershire elderly emergency care

(GEEC), championed by an ED consultant. The aim was to raise awareness of the issues faced by frail elderly patientsin the emergency department and to identify areas where the experience of this patient group could be improved.

• Multi-agency management plans had been developed for patients with mental health needs who were frequentattenders in the ED. These enabled staff to better support patients and had resulted in a reduction of both EDattendances and admissions to hospital.

• The trust’s referral to treatment time (RTT) for admitted pathways for medical services has been better than theEngland overall performance.

• The average length of stay was for non-elective patients were better than the England average.• Staff in theatres and recovery had guidance in place to help reduce the anxiety of patients living with dementia when

they using their services.• Rapid access assessment clinics were provided in some specialities, and some clinics were performing airway

assessments via skype.• The hospital had introduced a new waiting list validation process to discharge patient’s ongoing follow up care to

community based services such as GPs.• A project placing therapists on wards had helped increased patient discharges, and radiographers attended ward

briefings to identify inpatients waiting for scans.• The in-patient specialist palliative care team was available to ward staff to provide advice and training regarding

communication and end of life care; this included communicating with patients and carers.• The trust was one of two sites in the country which had been developing a medical examiner role and improved

death certification process project since 2008. Benefits included better support for relatives over the explanation andcauses of death as well as ensuring better oversight of signing of death certificates

• The specialist palliative care team responded promptly to referrals, usually within one working day.

Well-led

We rated well-led domain as requires improvement in medical care and good in urgent and emergency care and end oflife care.

• There was a strong, cohesive and well-informed leadership team within the emergency and urgent care service whowere highly visible and respected. The service had a detailed improvement plan in place with clear milestones andaccountability for actions.

• The emergency department produced high quality information which analysed demand capacity and patient flow,and was used to inform the improvement plan.

• There were robust governance arrangements in place within the emergency and urgent care service. Clinical auditwas well-managed and used to drive service improvement. Risks were understood, regularly discussed and actionstaken to mitigate them.

Summary of findings


• There were cooperative and supportive relationships among staff. We observed exceptional teamwork, particularlywhen the emergency department was under pressure. Here, staff felt respected, valued and supported. Morale wasmostly positive, although to an extent was undermined by workload pressures. Service improvement waseverybody’s responsibility. Staff were encouraged and supported to undertake service improvement projects.

• The leadership and culture of the specialist palliative care team in the trust reflected the vision and values of thetrust. Leadership encouraged openness and transparency and promoted good quality care. There were leads on thewards for delivery of end of life care which supported the development of high quality end of life care.

• The trust had a clear vision and strategy to deliver care at end of life linked to national best practice includingPriorities for Care of the Dying Person set out by the Leadership Alliance for the Care of Dying Patient’s.

• The governance framework for end of life care ensured that responsibilities were clear and that quality, performanceand risks were understood and managed.

• Staff felt respected and valued. There was a strong emphasis on promoting the safety and wellbeing of staffdelivering end of life care in the community.

• Services within specialist palliative and end of life care had been continuously improved and sustainabilitysupported since the last inspection March 2015.

However:

• Safety concerns which we identified at our last inspection had not been addressed, despite the introduction of newprocesses. Patient flow remained the major barrier to progress. The emergency department’s management team didnot feel there was a culture of collective responsibility within the trust in relation to patient flow. There wasfrustration expressed that the emergency department bore a disproportionate level of risk, while the responsibilityfor the exit block sat with others. The emergency department was unable to influence the cultural shift which wasrequired to address this significant barrier to improving patient flow and capacity.

• Pressures faced by staff in the emergency department in relation to crowding were well understood and articulatedby the management team but it did not appear that the risks relating to staff wellbeing, resilience and sustainability,had been widely shared or escalated within the organisation and they were not included on the department’s riskregister.

• There was a limited approach to obtaining the views of people who used the service. Workload pressures preventedopportunities for staff reflection or meaningful staff engagement and involvement in shaping the service.

• There was no risk register specific to end of life care for the trust so there was no easy trust wide oversight of riskrelating to the service.

• There was a program of internal and national audits for end of life care, which were on time. However most localaudit activity had not yet benefited from a thorough analysis of the data produced.

• Within the medical service there was a lack of overview and governance around mortality and morbidity (M&M)meetings. Risks registered on the risk register were not always aligned with risks in the service.

• There was a lack of understanding of the risk to safe patient care, the acuity of patients have on daily basis.

We saw several areas of outstanding practice including:

• The diagnostic imaging department sent radiographers onto wards to liaise with staff to identify inpatients that werewaiting for scans, in order to help speed up treatment and ultimately discharge.

• The therapies department had placed occupational therapists and physiotherapists on wards over Christmas tosupport and speed up patient discharges during a period of high pressure.

• The inpatient specialist palliative care team had won an annual staff award the trust - patient’s choice award 2016.This was from patients and others who recognised the NHS staff who had made a difference to their lives.

Summary of findings


• The consultant in the end of life care team was part of a multi-disciplinary team who had won the national LindaMcEnhill award 2016. The award was recognition by the Palliative Care of People with Learning Disabilitiesprofessional network of excellence in end of life care for individuals with learning disabilities. Work includedimproving how different teams worked better together.

• The development of a training package for midwives to enable them to administer flu vaccinations to at risk womenhad meant that a high number of women who would otherwise have not had the flu vaccine had received it.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

• Review processes to monitor the acuity of patients to ensure safe staffing levels.• Ensure wards are compliant with legislation regarding the Control of Substances Hazardous to Health (COSSH).• Review processes for ensuring effective cleaning of ward areas and equipment and patient waiting areas.• Review the governance and effectiveness of care and treatment through participation in national audits.• Ensure staffing levels meet the acuity of patients.• Ensure patient records are kept securely at all times.• Ensure equipment is replaced to ensure safe diagnosis and treatment.• Ensure the medical day unit is suitable for the delivery of care and protects patients dingy and confidentiality.• Ensure all staff are trained and understand their responsibilities in a resuscitation situation.• Ensure resuscitation equipment is readily available and accessible to staff.• Ensure steps are taken to reduce the current typing backlog in some specialities.• Ensure specialities have oversight of all of their waiting lists.• Ensure that all information related to patients’ mental capacity and consent for ‘Do Not Attempt Cardio-Pulmonary

Resuscitation’ (DNA CPR) is available in patient records.• Ensure trust staff comply with all the requirements of the Mental Capacity Act (2005).• Ensure the emergency department is consistently staffed to planned levels to deliver safe, effective and responsive

care.• Review support staff functions to ensure the emergency department is adequately supported.• Ensure all staff are up-to-date with mandatory training.• Ensure patients arriving in the emergency department receive a prompt face-to-face assessment by a suitably

qualified clinician.• Improve record keeping so that patients’ records provide a contemporaneous account of assessment, care and

treatment.• Ensure patients in the emergency department receive prompt and regular observations and that early warning

scores are calculated, recorded and acted upon.• Ensure the mental health assessment room in the emergency department meets safety standards recommended by

the Royal College of Psychiatrists.• When using the day surgery unit for inpatients, provision must be made for the cleaning of the units at weekends and

to provide patients with clean water jugs and drinks.• Ensure emergency resuscitation trolleys are checked and have guidelines attached according to best practice

guidance and in line with trust policy.• Ensure the safe management of medicines at all times, including storage, use and disposal and the checking and

signed for controlled drugs. Ensure all drug storage refrigerator temperatures are checked and the results recordeddaily. Additionally if the temperatures fall outside of the accepted range action is taken and that action recorded.

• Ensure patient group directives are up to date and consistent in their information.• Ensure women attending the triage unit within the maternity service are seen within 15 minutes of arrival.

In addition the trust should:

Summary of findings


• Ensure all staff are compliant with efficient decontamination of hands on entering wards.• The medical service should collect information about mortality and morbidity (M&M) meetings electronically across

all services to ensure an audit trail is maintained and outputs governed.• Ensure emergency equipment (including resuscitation trolleys) is checked daily in line with trust policy and national

guidance.• Review processes to recognise and respond to blank boxes on prescription charts to make sure patients receive

medicines as prescribed.• Review the process to assess risks to patients and ensure a management plan is in place.• Review process to comply with VTE assessment in line with trust policy and national guidelines.• Ensure treatment pathways are reviewed and update to ensure best evidence-based treatment.• Ensure all staff receive yearly appraisals in line with trust policy.• Review process to ensure patients are reviewed by a consultant within 14 hours of admission in line with the London

Quality Standards (2013).• Review processes to ensure compliance with the accessible information standards.• Ensure areas used to admit patients in times of high organisational pressures are suitable and staffed to ensure safe

care and treatment of patients.• Ensure effective monitoring of clinical improvement and audits, including compliance with accurate and timely

NEWS assessments.• Ensure timely response to complaints in line with trust policy.• Ensure there are sufficient numbers of staff with appropriate skills and experience on each shift in diagnostic

imaging.• Ensure identification procedures in diagnostic imaging are robust and recorded.• Ensure all staff are up to date with mandatory training.• Ensure all patient’s referral to treatment times do not exceed national targets including cancer wait targets.• Ensure steps are taken to reduce the current reporting backlog.• Ensure diagnostic imaging examinations are reported within target for the accident and emergency department.• Ensure steps are taken to monitor and reduce the numbers of temporary notes in use.• Ensure all hazardous chemicals and cleaning products are securely stored.• Review facilities for staff to take breaks and make drinks away from clinical areas• Ensure staff can effectively trace patient records through the hospital.• Ensure disabled toilets have sufficient alarm systems.• Ensure all risk identified relating to the provision of end of life care is included on a risk register.• Ensure the training needs analysis for general staff on wards related to end of life care is completed by the trust end

of life care quality group• Consider involving specialist palliative care team and support teams in major incident plan practices or exercises.• Review the signage and consider if the system of using ‘white rose’ symbols to assist location of trust mortuaries is

effective• Ensure specialist palliative care team are able to use the results of the safety thermometer information in relation to

patients receiving end of life care.• Continue to work in collaboration with partners and stakeholders in its catchment area to improve patient flow

within the whole system, thereby taking pressure off the emergency department, reducing crowding and the lengthof time patients spend in the department.

• Ensure the emergency department is supported by the wider hospital and that there is more engagement fromspecialties in addressing the risks associated with patient flow.

• Ensure the workload pressures and impact on staff wellbeing, associated with crowding in the emergencydepartment, are understood, identified on the risk register and that staff are supported as appropriate.

• Ensure all staff within the specialities is aware of Never Events and the learning needed to prevent a reoccurrence.• Continue to make improvements with the reduction of surgical site infection rates.

Summary of findings


• Review the pre admission clinic area for comfort and suitability• Provide resuscitation equipment for the pre admission unit to ensure if a patient collapsed, they receive the correct

care in a timely manner.• Review the equipment in the pre-admission unit to ensure it meets the needs of the service.• Patient group directions (PGDs) should be reviewed as they were out of date and the correct authorisation signatures

should be included.• Continue to work on your action plan to address the shortfalls identified in the mortality outliers.• Review the lack of 24-hour emergency theatre to ensure no patients will be put at risk.• Continue to address issues resulting from the new computer system.• Improve the number of staff appraisals completed.• Reduce the number of patients who have their operation cancelled on the day of surgery, and reduce the number of

patients not rebooked within 28 days.• Ensure emergency trolleys on the neonatal and children’s units have a system that easily highlights if an emergency

trolley has been tampered with between routine checks.• Support all children’s services to contribute to infection prevention and control audits so that risk can be accurately

assessed.• Consider options of protecting children’s safety when waiting for appointments in parts of the hospital that are not

dedicated to paediatrics.• Continue with strategies to maintain staffing levels that meet national guidelines.• The trust should ensure electronic systems in place, especially for community midwives, enable them to input data

in a timely way. Additionally they should have mobile phones with better connectivity to ensure they receive theirmessages in a timely way.

• The trust should ensure that all inpatient venous thromboembolism (VTE) risk assessments are completed.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Summary of findings


Our judgements about each of the main services

Service Rating Why have we given this rating?Urgent andemergencyservices

Requires improvement ––– We have rated this service as requires improvementoverall because:

• We had concerns about patient safety,particularly when the department was crowded,which was a regular and frequent occurrence.Capacity was compromised because EDattendances were increasing, both in numbersand in terms of patient acuity. Lack of patientflow within the hospital and in the widercommunity created a bottle neck in the ED,creating pressures in terms of space and staffcapacity. This in turn increased the risk thatpatients may not be promptly assessed,diagnosed and treated.

• Crowding was compounded by a significantshortage of staff. There were particular concernswith regard to the lack of senior decision makersat night. Consultants were regularly workingadditional hours to support more juniorcolleagues at night. Support staffing was alsounder-resourced, putting more pressure onclinical staff.

• The trust was consistently failing to meet thenational standard which requires that 95% ofpatients are discharged, admitted or transferredwithin four hours of arrival at the emergencydepartment. A significant number of four hourbreaches were attributed to a shortage ofinpatient beds. The trust was not meeting thestandard which required that patients arereviewed by a doctor within one hour.

• Patients were not consistently assessedpromptly on arrival and in some cases a face toface assessment did not take place for sometime. Ongoing monitoring of patients was notundertaken with the required frequency. Thismeant there was a risk that seriously unwell ordeteriorating patients may not be identified andmanaged promptly.

• Patients’ records were not consistentlycompleted to provide an accurate record of careand treatment provided. Record keeping was

Summaryoffindings

Summary of findings


notably worse when the department wascrowded. Records did not assure us that patientsregularly had their pain or their skin integrityassessed or had been offered food and drink.

• Patients waited too long in the emergencydepartment after the decision had been made toadmit them to an inpatient bed. Patientsregularly queued in the corridors in theemergency department and their relativessometimes had to stand because there wasinsufficient seating. Despite the efforts of staff,patients’ comfort and dignity could not bemaintained in the corridor.

• Patients who attended the emergencydepartment with mental health needs did notalways access prompt assessment and supportfrom mental health practitioners, particularly ifthey attended out of hours. Although there was adesignated mental health assessment room, itdid not comply with safety standards and wasnot a welcoming space.

• Pressures faced by staff in the emergencydepartment in relation to crowding were wellunderstood and articulated by the managementteam. However, it did not appear that the risksrelating to staff wellbeing, resilience andsustainability had been widely shared orescalated within the organisation and they werenot included on the department’s risk register.

• Safety concerns which we identified at our lastinspection had not been addressed, despite theintroduction of new processes. Poor patient flowremained the major barrier to progress. Theemergency department’s management team didnot feel there was a culture of collectiveresponsibility within the trust in relation topatient flow. There was frustration expressedthat the emergency department bore adisproportionate level of risk, while theresponsibility for the exit block sat with others.The emergency department was unable toinfluence the cultural shift which was required toaddress this significant barrier to improvingpatient flow and capacity.

However:

Summaryoffindings

Summary of findings


• The emergency department was taking steps tomitigate the risks associated with crowding.Hourly board rounds conducted by seniorclinicians provided an overview of activity andprovided an opportunity to identify andcommunicate safety concerns to the site andtrust management teams.

• A patient safety checklist had been introduced,which provided a series of time-sequencedprompts for staff to undertake risk assessments,observations, tests and treatments. However, theuse of this documentation was yet to beembedded in practice and was not consistentlycompleted.

• There were few serious incidents reported inurgent and emergency care. We saw goodevidence that when incidents occurred, lessonswere learned and improvements were made.There was openness and transparency aboutsafety. Staff were familiar with theirresponsibilities under the Duty of Candourregulation.

• There were effective processes in place for theidentification and management of adults andchildren at risk of abuse and staff were familiarwith these.

• There was a range of recognised treatmentprotocols and care pathways. Compliance withpathways and standards was monitored throughparticipation in national audits. Performance innational audits was mostly in line with othertrusts nationally. There was evidence that auditwas used to improve performance, for examplein the treatment of sepsis.

• Nursing and medical staff received regularteaching and clinical supervision. Staff wereencouraged and supported to develop areas ofinterest in order to develop professionally andprogress in their careers.

• Care was delivered in a coordinated way withsupport from specialist teams and services, suchas the stroke team. There was a range ofadmission avoidance initiatives in place toimprove patient flow. These included thedischarge assessment team, the older people’sassessment and liaison service, the mental

Summaryoffindings

Summary of findings


health liaison service and the alcohol liaisonservice, who all worked closely andcollaboratively with the emergency department.The clinical commissioning group had alsocommissioned a pilot whereby GPs worked inthe ED on weekdays and appropriate patientswere streamed to see either a GP or an advancenurse practitioner.

• The emergency department had recentlydeveloped a team known as the Gloucestershireelderly emergency care (GEEC), championed byan ED consultant. The aim was to raiseawareness of the issues faced by frail elderlypatients in the emergency department and toidentify areas where the experience of thispatient group could be improved.

• Multi-agency management plans had beendeveloped for patients with mental health needswho were frequent attenders in the ED. Theseenabled staff to better support patients and hadresulted in a reduction of both ED attendancesand admissions to hospital.

• Complaints were listened to and acted upon.There was evidence that changes andimprovements had been made in response tocomplaints.

• All of the patients we spoke with during ourinspection commented very positively about thecare they received from staff. This was consistentwith the results of patient satisfaction surveys,which were mostly positive.

• Patients were treated with compassion andkindness. We saw staff providing reassurancewhen patients were anxious or confused.

• Patients were treated with courtesy, dignity andrespect. We observed staff greeting patients andtheir relatives and introducing themselves byname and role.

• Patients and their families were involved aspartners in their care. We heard doctors andnurses explaining care and treatment in asensitive and unhurried manner.

• There was a strong, cohesive and well informedmanagement team who were highly visible andrespected.

Summaryoffindings

Summary of findings


• There was an effective governance framework.Information was regularly monitored to providea holistic understanding of performance, whichincluded safety, quality and patient experience.Risks were understood, regularly discussed andactions taken to mitigate them.

• The emergency department had developed animprovement plan with clear milestones andaccountability for actions.

• Staff morale was mainly positive, although thishad been somewhat overshadowed by crowdingand the pressures this placed on staff. Staffnevertheless felt valued and supported.

• There were cooperative and supportiverelationships among staff. We observedexceptional teamwork, particularly when thedepartment was under pressure.

• There was a strong focus on learning andimprovement. Clinical audit was well managedand used to drive improvement. Mistakes wereopenly discussed and learning acted upon. Staffat all levels were encouraged to play their part inimproving patient experience.

Medical care(includingolderpeople’scare)

Requires improvement ––– We rated this service as requires improvementbecause:

• Nursing staffing levels were below establishmentand wards relied on bank and agency to covershifts every day.

• Theservice did not assess or record the acuity ofpatients on each shift and on each ward toensure safe staffing levels.

• The medical service did not consistently reviewthe effectiveness of care and treatment throughnational audits.

• The service had a strategy to understand andimprove performance on hospital-basedmortality indicators. While most specialities heldmortality and morbidity (M&M) meetingsmonthly or quarterly we were concerned thatnot all specialties held meetings regularly andhow effectively learning was shared.

• There were some concerns about the safetransfer of patients receiving intravous therapyduring ambulance transfers to other hospitals.

Summaryoffindings

Summary of findings


• Staff did not always follow infection controlprocedures when entering wards and ensuringthe cleanliness of equipment such ascommodes.

• Staff did not always comply with legislationregarding the Control of Substances Hazardousto Health (COSHH).

• Daily checking of equipment such asresuscitation equipment was not carried out inline with the trust’s policy in all areas.

• Staff did not monitor fridge temperaturesconsistently or take actions where these fell outof normal range, which meant medicines werenot always stored correctly.

• Staff were unsure of when to dispose of somemedicines in line with manufacturer’srecommendations.

• Records were not stored safely to ensurepatient’s confidentiality was maintained.

• Staff did not always assess risks to patients orfollow up identified risks with mitigating careinterventions.

• The medical service did not consistently reviewthe effectiveness of care and treatment throughnational audits.

• Staff did not always put actions in place whenpatients were at risk of malnutrition.

• Compliance with annual appraisals were belowthe trust’s target.

• There were delays in discharging patients;although this was largely caused by factorsoutside of the medical services remit.

• Information was not always accessible to staffincluding information about care and treatmentpathways.

• The delivery of cardiology services did not meetthe needs of the local population.

• There were delays to discharges, which meantpatient flow through the hospital wascompromised.

• The environment did not meet the needs ofpatients with dementia.

Summaryoffindings

Summary of findings


• The service was not always compliant with theaccessible information standards andinformation leaflets were not readily available forpatients for whom English was not their firstlanguage.

• Risks registered on the risk register were notalways aligned with risks in the service

• There was a limited approach to obtaining theviews of patients and their relatives

However:

• Staff understood their responsibility to reportincidents and there were processes in place toreview incidents and ensure learning was sharedacross the trust.

• The endoscopy unit had safe processes in placeto ensure staff decontaminated and sterilisedequipment in line with best practice.

• Staff were aware of their responsibilities foridentifying and reporting safeguarding issues.

• There were safe processes in place to reviewpatients and ensure care and treatment planswere followed up.

• Patients were positive about the way they weretreated and cared for in the medical wards.Where staff were observed treating patients withkindness, dignity, respect and compassion.

• Patients praised staff for providing furtherinformation when asked.

• There was a competence training andassessment framework in place to ensure nurseswere competent to carry out extended skills andnursing staff were supported with revalidationprocesses.

• There was an effective framework for ‘boardround’ and ward rounds and included input fromstaff from the multidisciplinary healthcare team.

• Processes were in place to ensure consultantsreviewed patients seven days a week.

• Staff were aware of the mental capacityassessment and applications for deprivation ofliberty safeguards.

• The trust’s referral to treatment time (RTT) foradmitted pathways for medical services wasbetter than the England overall performancebetween November 2015 and October 2016.

Summaryoffindings

Summary of findings


• The trust had a clear vision and some specialitieswithin the medical division had a vision toexpand and improve services.

• Staff felt supported by managers and seniormanagement felt assured by the new executiveteam.

Surgery We did not rate this service as we did not inspect alldomains. However, we found:

• Since our inspection in March 2015, the numberof surgical site infection rates had increased forreplacement hips, knees, and spinal surgery.

• There had been two never events reported insurgery since our last inspection. These hadbeen investigated and actions taken to preventthese happening again.

• Storage for patients’ notes on some wards andunits was not secure, which meant unauthorisedpeople could have had access to theseconfidential records.

• Mandatory training for all staff was not meetingthe trust’s target.

• The surgical division was not meeting the trust’starget for staff appraisals.

• Due to pressure for beds and the demand forservices, some patients had to use facilities andpremises that were not always appropriate forinpatients and support services were not alwaysset up and staff did not know how to set themup.

• Elective operations were being cancelled due tothe pressure on the beds within the trust, andsurgical wards were being used to accommodatemedical patients.

• The trust had introduced a new computersystem prior to our inspection that was causingsome issues for staff resulting in 'work around'processes to prevent any risks to patients.

However:

• The service encouraged openness andtransparency from staff with incident reporting,and incidents were viewed as a learningopportunity. Staff felt confident in raisingconcerns and reporting incidents.

Summaryoffindings

Summary of findings


• The trust had been identified as a ‘mortalityoutlier’ in to relation Reduction of fracture ofbone (Upper/Lower limb)’ procedures, whichincluded fractured hip. However, the actions theyhad implemented had made improvements andthese were ongoing at the time of our inspection.For example, in the 2016 hip fracture audit whichhad shown an improvement on 2015 audit

• Training in safeguarding of adults and childrenhad met the trust target for completion.

Maternityandgynaecology

We did not rate this service as we did not inspect alldomains. However, we found:

• All areas had access to emergency resuscitationtrolleys. However, in some areas, a systematiccheck of the trolleys was not documented ashaving being carried out on a daily basis. Therewere no up to date Resuscitation Council (UK)guidelines available on the resuscitation trolleys.Intravenous fluids on the emergencyresuscitation trolleys were not stored securely toensure they were tamper proof. This meant staffcould not be assured the right equipment andguidance would be available in the case of anemergency.

• Not all drug storage fridge temperatures weredocumented daily. There was no process inplace if a temperature fell outside of acceptablelimits. This meant staff could not be assuredmedicines requiring refrigeration were beingstored at the required temperatures.

• There were a number of out of date patientgroup directives (PGD’s) in use in maternityservices. The lists of medicines that were subjectto PGD’s had no doses or route of administrationdetailed on them. We drew this to the attentionof senior staff and the PGD’s were removed fromuse.

• Community midwives could not always print outclinical notes from the electronic system to gointo women’s handheld notes. They alsoreported poor mobile phone coverage whichmeant there was sometimes a delay in gettingmessages. This could have an impact on awoman who was trying to get some help oradvice from a midwife.

Summaryoffindings

Summary of findings


• An electronic patient record system had beenintroduced trust wide in December 2016. Therewere some ongoing issues with allocation ofbaby NHS numbers and records migrating to thenew system. This meant that babies may missout on vital tests following birth. Midwives haddevised solutions to ensure each baby had anNHS number.

• Senior House Officers (SHO) did not attend skillsdrills training when they started at the trust.Those that spoke to us said whilst they did notcover the delivery suite they did carry anemergency bleep and if they arrived in thedelivery suite first they often felt out of theirdepth.

• There were often long waiting times in the triagearea. Whilst systems were being put in place toincrease medical and midwifery staffing, womenwere not seen within 15 minutes of attending theunit. This could mean that urgent issues may bemissed.

• Consultant presence, on labour suite, was belowthe recommendations of the Royal College ofObstetricians and Gynaecologists (RCOG) SaferChildbirth (2007) guidance.

• Speciality trainee doctors (ST3 and ST4) andsome consultants felt that a senior house officerequivalent was needed at night as sometimes noother medical staff to assist with emergencycaesarean sections were available. This alsomeant other patients, across maternity andgynaecology services, who needed to see adoctor sometimes had to wait for long periods oftime.

• The morning medical handover was informaland there was no input from the co-ordinatingmidwife about the women in labour at the timeof the meeting. The registrar who had been onduty overnight presented the cases but said theywere often tired and did not always have the fullup to date details of the women. This may meanthat the most up to date information is not beinggiven to the next staff coming on duty.

However:

Summaryoffindings

Summary of findings


• Staff understood their responsibilities to raiseconcerns and report incidents using theelectronic reporting system. There was a cultureof shared learning from incidents.

• Staff spoke confidently about the duty ofcandour and gave examples of where it hadbeen applied. Relevant staff had receivedtraining.

• All areas we visited were visibly clean and tidy.There were antibacterial hand sanitizers at theentrances to each unit/ward. Staff were seenadhering to the trusts infection control policiesincluding ‘bare below the elbows”. This meantpeople visiting the maternity services wereprotected from the spread of infection.

• All rooms on the delivery suite, including thetriage area had wireless cardiotochograph (CTG)machines for monitoring the foetal heart. TheCTG machines were linked to a central monitorpoint, which allowed the co-ordinating midwifeto review traces. The wireless aspect meantwomen could still be monitored whilst in abirthing pool.

• Doors into all wards/units were locked, with abuzzer entry system and CCTV. Althoughreception areas were not manned 24 hours perday; when there was no receptionist other staffon duty took on the role. A baby security taggingsystem was in place on the maternity unit.

• There were systems in place for recognising andreporting safeguarding concerns. Staff wereconfident to raise any matters of concern andescalate them as appropriate.

• A ‘vulnerable women’s team’ had beendeveloped that included a full time perinatalmental health midwife, substance misuse andteenage pregnancy midwife and the leadsafeguarding midwife. The team were able tooffer an enhanced service to those womenidentified as being at risk. The team also offeredadvice and support to midwives who hadconcerns.

• Staff said there was good access to mandatorytraining. Mandatory training for maternity

Summaryoffindings

Summary of findings


services included a PROMPT (Practical ObstetricMulti-Professional Training) skills drills trainingday and a one-day maternity update for staffworking within the maternity unit.

• The maternity services offered Birth ChoicesClinic for women identified as being high risk butwho requested midwife-led care. They were seenby a supervisor of midwives and a complex careplan devised in agreement with the woman andin discussion with an obstetrician.

• The service had a commitment to managingwomen’s peri-natal mental health issues andwere trying to establish a team to include aconsultant psychiatrist.

• The development of a training package formidwives to enable them to administer fluvaccinations to at risk women had meant that ahigh number of women who would otherwisehave not had the flu vaccine had received it.

• The gynaecology ward had been relocated, inDecember 2016, to a ward with less beds (20beds to 13 beds) to reduce the incidence ofoutlying patients (that is patients from medicalor surgical wards) which sometimes meantelective gynaecology surgery had to becancelled. The ward sister said the number ofoutliers had reduced significantly and as a resultthere were less elective gynaecology proceduresbeing cancelled.

• The clinical scorecard between April 2016 andNovember 2016 showed that staff were providingone-to-one care in labour 98% of the time.

• A telephone triage system staffed by midwiveswas located within an ambulance service hub.Midwives directed women to the mostappropriate place for their care. The system hadreduced the volume of calls directly to the triagearea.

• There was 24-hour consultant on-call cover. Thedelivery suite had access to anaesthetists 24hours a day, seven days a week. Doctors wespoke with said that consultants always came inat night if they were asked to.

Summaryoffindings

Summary of findings


Services forchildren andyoungpeople


• There was an open reporting culture by staff whoworked in the children’s services. This helped tomaintain the safety of treatment and care forbabies, children and young people.

• There was evidence to show incidents, concernsor trends were investigated for learningopportunities and actions taken to improvepractice.

• Staff understood their roles and responsibilitiesto safeguard children from potential risks orabuse and received supervision on a regularbasis. The trust’s safeguarding teams workedwith community and social care colleagues toidentify and support children who may be at risk.

• Systems for staff shift handovers promoted thesafety of children. Staff were fully included inprocesses and encouraged to contribute.

• Records showed electrical and mechanicalequipment was regularly maintained to ensure itwas safe to use and review dates were clearlyindicated.

• Risk assessments were used with all children toidentify the level of care they needed. Thesewere audited regularly to check they had beencompleted correctly and concerns had beenescalated for further advice where necessary.

• Staffing levels were regularly reviewed andplanned to follow national guidelines andstandards. However, staffing levels had beenchallenged with unexpected staff absences.Managers were taking steps to fill gaps in theshort term, recruit staff on a permanent basisand maintain staffing levels.

However:

• Compliance with audit processes for infectionprevention and control was variable across thechildren’s services and had not been consistentlycompleted.

• Routine stock checks of some medicines werenot always completed according to the trustprotocol.

Summaryoffindings

Summary of findings


End of lifecare

Good ––– We rated this service as Good because:

• End of life care provided at Gloucestershire RoyalHospital was safe, effective caring, responsiveand well led because:

• The processes in place to keep people safe forend of life care were good. Staff in the end of lifecare team and other areas understood theirresponsibilities to raise concerns, record safetyincidents and report them. Lessons were learnedand improvements were made when things wentwrong.

• Patient’s records demonstrated that nutritionand hydration needs were assessed andappropriate actions were documented asfollowed in patients’ individual care plans.

• Records documented discussions with relativesaround what to expect with the dying process.

• Risks to patient’s receiving care at end of lifewere assessed by ward staff with appropriateassessments recorded in medical records forexample the prevention and management ofpressure ulcers and falls.

• Staff we spoke with on the wards understoodthat end of life care could cover an extendedperiod for example in the last year of life and alsoapplied to patients with non-cancer diagnosessuch as dementia. Staff, teams and servicesworked together to deliver effective care andtreatment.

• Staff we observed on wards and in thecommunity delivering end of life care to patientswere compliant with key trust policies such asinfection control.

• Arrangements in place for managing medicineskept patients safe. Medicines to relieve pain andother symptoms were available at all times.Wards had adequate supplies of syringe drivers(devices for delivering medicines continuouslyunder the skin) and the medicines to be usedwith them.

• There were reliable systems, processes andpractices in place to keep patients safe andsafeguarded from abuse.

• The staffing levels and skill mix of the nurse andmedical personnel in the specialist palliativecare team were planned and reviewed and

Summaryoffindings

Summary of findings


supported safe practice. We saw evidence of ayearly education programme of end of life carefor medical, nursing and allied healthprofessionals. This included: resuscitation,syringe driver training, quarterly end of life studydays and symptom management.

• The specialist palliative care team respondedpromptly to referrals, usually within one workingday.

• Patients were treated with kindness, dignity,respect and compassion. Staff took the time tointeract with people who received end of life careand those close to them in a respectful andconsiderate manner.

• We saw many written compliments about howcaring staff were in the inpatient and communityspecialist palliative care team. We saw thatpatients’ and those people close to them, wereinvolved as partners in their care.

• The specialist palliative care team and wardsstaff understood the impact a patients’ care,treatment or condition had on their wellbeingand on those people close to them.

• Emotional support for patients and relatives wasavailable through the in-patient and communityspecialist palliative care team, the chaplaincyteam and bereavement services. Staff had accessto support through their own teams whenneeded.

• Services were delivered and additional servicesplanned in order to effectively meet patient’sneeds. Plans and actions included audit toinform future planning so that the end of lifeteam could inform better decision making withpatients they cared for

• The bereavement office was one of two sites inthe country involved in a pilot project to improvedeath certification which was more supportive tobereaved relatives and provided better oversightof causes of death.

• There was a clear vision and strategy to delivercare at end of life. The governance framework forend of life care ensured that responsibilities wereclear and that quality, performance and riskswere understood and managed.

Summaryoffindings

Summary of findings


• Leadership encouraged openness andtransparency and promoted good quality care.There were leads on the wards who supportedthe development and delivery of high qualityend of life care.

• Services within specialist palliative and end oflife care had been continuously improved andsustainability supported since the last inspectionMarch 2015.

However:

• Documenting ‘Do Not AttemptCardio-Pulmonary Resuscitation’ (DNACPR)decisions had improved since the last inspectionhowever concerns regarding DNACPR remained.For example not all DNACPR having relevantclinical information and not all patients or thoseclose to them being recorded as involved indiscussions about resuscitation. These concernswere not identified as a risk and did not featureon a risk register

• There were no centrally held training records forsyringe driver training or competency for wardstaff.

• There was not a full understanding ofperformance for all aspects of end of life care.For example the percentage of patients dying intheir preferred location and the percentage ofpatients discharged within 24 hours were notknown for all wards or hospital sites.

• There was no risk register specific to end of lifecare for the trust so oversight of all end of life riskwas not easy.

• When we reviewed maintenance records someprovided were out of date. The trust told us theywere clear that equipment listed was not in use.We saw email communication from directorssupporting this.

• There was not a seven day face to face serviceprovided by the in-patient and community endof life care team. The trust provided a face to faceservice 9-5 Monday to Friday. Out-of-hours therewas a telephone advice line available 24 hours, 7days a week for health care professionals toaccess.

Summaryoffindings

Summary of findings


• Some of the ‘white rose’ symbols used to locatethe mortuary at the hospital were not easy tofollow. Signs were not always at eye level forsomeone walking or in a wheelchair and therewere long gaps in signage that led to confusion.Mortuary and bereavement officers told usrelatives had commented they were useful.Some relatives had reported they appreciatedthese signs. However bereavement office staffaccompanied relatives when they knew peoplewere attending the mortuary.

Outpatientsanddiagnosticimaging


• The service did not have sufficient arrangementsto keep clinical and patient areas clean. Therewas no cleaning carried out over the weekend indiagnostic imaging, and some outpatienttreatment rooms and waiting areas were visiblydirty.

• There was not a reliable system to track thenumber of temporary notes being used since theimplementation of a new computer system, andstaff were finding it difficult to trace patientnotes.

• There were not sufficient arrangements toensure staff had access to or knew where toaccess emergency equipment. Some staff wereunsure of their responsibilities in a resuscitationsituation, and staff in ophthalmology did notknow where to locate their nearest defibrillator.

• Patients were not protected from avoidableharm in the therapies department as cleaningchemicals were not stored securely.

• The hospital was not meeting the 62 day waitinglist target for cancer patients.

• Patients were experiencing delays in diagnosisand treatment because the diagnostic imagingdepartment had a reporting backlog of 19,500films, and was not meeting its five day reportingtarget for accident and emergency x-rays.

• A significant typing backlog was causing delaysin sending out patient letters impacting onpatient safety, diagnosis and ongoing treatment.

Summaryoffindings

Summary of findings


• Implementation of new IT systems had impactedon waiting lists as some specialties could not seetheir live waiting lists.

• The trust was not meeting referral to treatmenttarget in all specialities, and patients werewaiting longer for to access care and treatment.

However;

• Incident reporting had improved and in one casethe trauma and orthopaedic department to takesteps to reduce pressure ulcers. Staff confirmedthey now received feedback from incidents theyreported.

• The diagnostic imaging department conductedinvestigations and had raised safety alerts withan equipment manufacturer which had resultedin changes to practice.

• Cleaning and infection control procedures hadimproved in ophthalmology since the lastinspection, and there were gooddecontamination processes in other outpatientdepartments for equipment that was re-useable.

• Diagnostic imaging were negotiating one costservice and maintenance contracts for scannersand equipment.

• Patient were able to access services when theyneeded to and rapid access assessment clinicswere provided in some specialities, and someclinics were performing airway assessments viaskype.

• The hospital had introduced a new waiting listvalidation process to discharge patients’ ongoingfollow up care to community based services suchas GPs.

• A project placing therapists on wards had helpedincrease patient discharges, and radiographersattended ward briefings to identify inpatientswaiting for scans.

Summaryoffindings

Summary of findings


GloucGloucestesterershirshiree RRoyoyalalHospitHospitalal

Detailed findings

Services we looked at<Delete services if not inspected> Urgent and emergency services; Maternity (community services);Maternity (inpatient services); Surgery (gynaecology); Spinal injuries centre; Medical care (including olderpeople’s care); Surgery; Specialist burns and plastic services; Critical care; Maternity and gynaecology;Services for children and young people; End of life care; Outpatients and diagnosticimaging; Chemotherapy; Radiotherapy; Renal; Elective orthopaedic centre; Sexual health services; Adultsolid tumours; Haematology; Specialised rehabilitation


Contents

PageDetailed findings from this inspectionBackground to Gloucestershire Royal Hospital 31

Our inspection team 32

How we carried out this inspection 32

Facts and data about Gloucestershire Royal Hospital 32

Our ratings for this hospital 33

Findings by main service 34

Action we have told the provider to take 172

Background to Gloucestershire Royal Hospital

Gloucestershire Hospitals NHS Foundation Trust providesacute hospital services to a population of around 612,000people in Gloucestershire and the surrounding areas.

The trust has three main locations that are registeredwith the Care Quality Commission (CQC), which areGloucestershire Royal Hospital, Cheltenham GeneralHospital and Stroud Maternity Hospital. There are 1,075beds across these three hospitals. There are 683 beds atGloucestershire Royal Hospital.

The trust was formed in 2002 with the merger ofGloucestershire Royal and East Gloucestershire NHSTrusts, and became an NHS foundation trust in July 2004.

The health of people in Gloucestershire is generally betterthan the England average. Deprivation is lower thanaverage, however about 13.8% (14,600) of children live inpoverty. Life expectancy for both men and women ishigher than the England average. Life expectancy is 7.8years lower for men and 6.3 years lower for women in themost deprived areas of Gloucestershire than in the leastdeprived areas.

In the latest financial year, 2015/16, the trust had anincome of £498.9 million, and costs of £494.3 million,meaning it had a surplus of £4.6 million for the year. Atthe time of inspection, the trust predicted it would have adeficit of £18.7 million in 2016/17.

Activity and patient throughput. In 2015/16 the trust as awhole had:

• 127,369 A&E first attendances

• 114,328 Inpatient spells (51,932 non-elective, 62,396elective)

• 451,771 Outpatient attendances

• 6,388 births

• 2,067 referrals to the specialist palliative care team

This was a focused inspection to follow-up on concernsfrom a previous inspection. As such, not all domains wereinspected in all core services.

The inspection team inspected the following seven coreservices at Gloucestershire Royal Hospital:

• Urgent and emergency services• Medical care (including older people’s care)• Surgery• Maternity and gynaecology• Services for children’s and young people• End of life care• Outpatients and diagnostic imaging

Detailed findings


Our inspection team

Our inspection team was led by:

Chair: Anthony Berendt, Medical Director, OxfordUniversity Hospitals NHS Foundation Trust

Head of Hospital Inspections: Mary Cridge, Head ofHospital Inspections, Care Quality Commission

The team included CQC inspectors and a variety ofspecialists: directors of nursing and governance,

consultants and medical staff from medicine, surgery,emergency services, paediatrics, a junior doctor; a seniormidwife; senior nurses in paediatrics, medicine, surgery,theatres, care of the elderly and palliative care. The teamalso included one expert by experience, analysts and aninspection planner.

How we carried out this inspection

Before visiting, we reviewed a range of information weheld and asked other organisations to share what theyknew about Gloucestershire Royal Hospital. Theseincluded the local clinical commissioning group, NHSImprovement, the local council, GloucestershireHealthwatch, mental health and community partnerorganisations, the General Medical Council, the Nursingand Midwifery Council and the royal colleges.

People who used the services were able to share theirexperiences by email and telephone and on our website.We also collected feedback from patients and relatives oncomment cards during the inspection.

We carried out an announced inspection 24-27 January2017 and an unannounced inspection at GloucestershireRoyal on 6 February 2017. We held focus groups anddrop-in sessions with a range of staff including nurses,junior doctors, consultants, student nurses,

administrative and clerical staff, physiotherapists,occupational therapists, pharmacists, domestic staff,porters and maintenance staff. We also spoke with staffindividually as requested.

We talked with over 180 staff and 60 patients. Weobserved how people were being cared for, talked withcarers and family members, and reviewed over 60patients’ records of their care and treatment.

As part of this inspection, CQC piloted an enhancedmethodology relating to the assessment of mental healthcare delivered in acute hospitals; the evidence gatheredusing the additional questions, tested as part of this pilot,has not contributed toour aggregation of judgements forany rating within this inspection process. Whilst theevidence is not contributing to the ratings, we havereported on our findings in the report.

Facts and data about Gloucestershire Royal Hospital

Gloucestershire Hospitals NHS Foundation Trust providesacute hospital services to a population of around 612,000people in Gloucestershire and the surrounding areas.

The trust has three main locations that are registeredwith the Care Quality Commission (CQC), which areGloucestershire Royal Hospital, Cheltenham GeneralHospital and Stroud Maternity Hospital. There are 1,075beds across these three hospitals. There are 683 beds atGloucestershire Royal Hospital.

In the latest financial year, 2015/16, the trust had anincome of £498.9 million, and costs of £494.3 million,meaning it had a surplus of £4.6 million for the year. Thetrust predicts it will have a deficit of £18.7 million in 2016/17.

Activity and patient throughput. In 2015/16 the trust had:

• 127,369 A&E first attendances• 114,328 Inpatient spells (51,932 non-elective, 62,396

elective)• 451,771 Outpatient attendances

Detailed findings


• 6,388 births• 2,067 referrals to the specialist palliative care team

Between Q1 2015/16 and Q2 2016/17, the trust’s bedoccupancy has been consistently higher than the Englandaverage by 2 to 8%. This was above the level, 85%, atwhich it is generally accepted that bed occupancy canstart to affect the quality of care provided to patients andthe orderly running of the hospital.

The executive team had recently undergone a period ofsignificant change having been a previously stable andlongstanding board. The previous chief executive retiredin April 2016 having been chief executive since 1 May

2008. The new chief executive took up their role in June2016. A new chairman joined the trust in November 2016.The finance director and two non-executive directorsstood down in September 2016. The two non-executivedirectors had been replaced at the time of the inspection.There was an interim chief operating officer and aninterim finance director in post.

CQC inspection history

Gloucestershire Hospitals NHS Foundation Trust has hada number of inspections since first registering with CQC.The last inspection occurred in March 2015 and was a fullannounced comprehensive inspection.

Our ratings for this hospital

Our ratings for this hospital are:

Safe Effective Caring Responsive Well-led Overall

Urgent and emergencyservices

Requiresimprovement Good Good Requires

improvement Good Requiresimprovement

Medical care Requiresimprovement

Requiresimprovement Good Requires

improvementRequires

improvementRequires

improvement

Surgery Requiresimprovement Good N/A Requires

improvement N/A N/A

Maternity andgynaecology

Requiresimprovement N/A N/A N/A N/A N/A

Services for childrenand young people Good N/A N/A N/A N/A N/A

End of life care Good Good Good Good Good Good

Outpatients anddiagnostic imaging

Requiresimprovement N/A N/A Requires

improvement N/A N/A

Overall Requiresimprovement N/A N/A N/A N/A N/A

Detailed findings


Safe Requires improvement –––

Effective Good –––

Caring Good –––

Responsive Requires improvement –––

Well-led Good –––

Overall Requires improvement –––

Information about the serviceUrgent and emergency care and treatment is provided atGloucester Royal Hospital (GRH) by the unscheduled careservice, which forms part of the medical division. There isan Emergency Department (ED), otherwise known as theAccident & Emergency Department, which operates 24hours a day, seven days a week. The ED saw 81,884patients in 2015/16, of which 15,256 were children (under17 years of age). Trust-wide, the proportion of EDattendances that resulted in a hospital admission was33.5%, which was slightly higher than the previous yearand significantly higher than the England average(22.2%). This may indicate that the department seesmore acutely unwell patients.

The ED is designated as a trauma unit and provides carefor all but the most severely injured trauma patients, whowould usually be taken by ambulance to the majortrauma centre in Bristol if their condition allows them totravel directly. If not, they may be stabilised at GRH andeither treated or transferred as their condition dictates.The department is served by a helipad.

ED patients receive care and treatment in two main areas;minors and majors. Self-presenting patients with minorillness or injury are assessed and treated in the minors’area. There is a GP present in the department on someweekdays who sees people with minor illness. There aretwo waiting areas; one for adults and a second smallerarea for children. Patients with serious injury or illnesswho arrive by ambulance are seen and treated in the

majors’ area, which includes a four bay resuscitationroom. The majors’ area is accessed by a dedicatedambulance entrance and the resuscitation room islocated just inside this entrance.

This was a follow-up inspection to assess the progressmade by the trust following our last comprehensiveinspection, which took place in March 2015. Urgent andemergency services at that time were rated as ‘requiresimprovement’ overall.

We visited the department over one and a half weekdaysas part of our announced inspection. We returnedunannounced for a further day. We spoke withapproximately 20 patients and relatives. We spoke withstaff, including nurses, doctors, managers, therapists,support staff and ambulance staff. We observed care andtreatment and looked at care records. We receivedinformation from people who completed comment cardsor contacted us to tell us about their experiences. Prior toand following our inspection, we reviewed performanceinformation about the trust and information from thetrust.


Emergency and urgent services provided by the trust arelocated on two hospital sites, the other being

Urgentandemergencyservices

Urgent and emergency services


Cheltenham General Hospital (CGH). Services at CGH arereported on in a separate report. However, services onboth hospital sites are run by one management team andwithin the trust are largely regarded as one service, withsome staff rotating between the two sites. For this reasonit is inevitable that there is some duplication contained inthe two reports.

Summary of findingsWe have rated this service as requires improvementoverall because:

• We had concerns about patient safety, particularlywhen the department was crowded, which was aregular and frequent occurrence. Capacity wascompromised because ED attendances wereincreasing, both in numbers and in terms of patientacuity. Lack of patient flow within the hospital and inthe wider community created a bottle neck in the ED,creating pressures in terms of space and staffcapacity. This in turn increased the risk that patientsmay not be promptly assessed, diagnosed andtreated.

• Crowding was compounded by a significant shortageof nurses, junior and middle grade doctors. Therewas a heavy reliance upon bank and agency nursingstaff, locums and consultants acting down toshortfalls in junior cover. There were particularconcerns with regard to the lack of senior decisionmakers at night. Consultants were regularly workingadditional hours to support more junior colleaguesat night. Support staffing was also under-resourced,putting more pressure on clinical staff.

• The trust was consistently failing to meet thenational standard which requires that 95% ofpatients are discharged, admitted or transferredwithin four hours of arrival at the emergencydepartment. A significant number of four hourbreaches were attributed to a shortage of inpatientbeds. The trust was not meeting the standard whichrequired that patients are reviewed by a doctorwithin one hour.

• Patients were not consistently assessed promptly onarrival and in some cases a face to face assessmentdid not take place for some time. Ongoingmonitoring of patients was not undertaken with therequired frequency. This meant there was a risk thatseriously unwell or deteriorating patients may not beidentified and managed promptly.

• Patients’ records were not consistently completed toprovide an accurate record of care and treatmentprovided. Record keeping was notably worse when




the department was crowded. Records did notassure us that patients regularly had their pain ortheir skin integrity assessed or had been offered foodand drink.

• Patients waited too long in the emergencydepartment after the decision had been made toadmit them to an inpatient bed. Patients regularlyqueued in the corridors in the emergencydepartment and their relatives sometimes had tostand because there was insufficient seating. Despitethe efforts of staff, patients’ comfort and dignitycould not be maintained in the corridor.

• Patients who attended the emergency departmentwith mental health needs did not always accessprompt assessment and support from mental healthpractitioners, particularly if they attended out ofhours. Although there was a designated mentalhealth assessment room, it did not comply withsafety standards and was not a welcoming space.

• Pressures faced by staff in the emergencydepartment in relation to crowding were wellunderstood and articulated by the managementteam. However, it did not appear that the risksrelating to staff wellbeing, resilience andsustainability had been widely shared or escalatedwithin the organisation and they were not includedon the department’s risk register.

• Safety concerns which we identified at our lastinspection had not been addressed, despite theintroduction of new processes. Poor patient flowremained the major barrier to progress. Theemergency department’s management team did notfeel there was a culture of collective responsibilitywithin the trust in relation to patient flow. There wasfrustration expressed that the emergencydepartment bore a disproportionate level of risk,while the responsibility for the exit block sat withothers. The emergency department was unable toinfluence the cultural shift which was required toaddress this significant barrier to improving patientflow and capacity.

However:

• The emergency department was taking steps tomitigate the risks associated with crowding. Hourly

board rounds conducted by senior cliniciansprovided an overview of activity and provided anopportunity to identify and communicate safetyconcerns to the site and trust management teams.

• A patient safety checklist had been introduced,which provided a series of time-sequenced promptsfor staff to undertake risk assessments, observations,tests and treatments. However, the use of thisdocumentation was yet to be embedded in practiceand was not consistently completed.

• There were few serious incidents reported in urgentand emergency care. We saw good evidence thatwhen incidents occurred, lessons were learned andimprovements were made. There was openness andtransparency about safety. Staff were familiar withtheir responsibilities under the Duty of Candourregulation.

• There were effective processes in place for theidentification and management of adults andchildren at risk of abuse and staff were familiar withthese.

• There was a range of recognised treatment protocolsand care pathways. Compliance with pathways andstandards was monitored through participation innational audits. Performance in national audits wasmostly in line with other trusts nationally. There wasevidence that audit was used to improveperformance, for example in the treatment of sepsis.

• Nursing and medical staff received regular teachingand clinical supervision. Staff were encouraged andsupported to develop areas of interest in order todevelop professionally and progress in their careers.

• Care was delivered in a coordinated way withsupport from specialist teams and services, such asthe stroke team. There was a range of admissionavoidance initiatives in place to improve patient flow.These included the discharge assessment team, theolder people’s assessment and liaison service, themental health liaison service and the alcohol liaisonservice, who all worked closely and collaborativelywith the emergency department. The clinicalcommissioning group had also commissioned a pilotwhereby GPs worked in the ED on weekdays andappropriate patients were streamed to see either aGP or an advance nurse practitioner.




• The emergency department had recently developeda team known as the Gloucestershire elderlyemergency care (GEEC), championed by an EDconsultant. The aim was to raise awareness of theissues faced by frail elderly patients in the emergencydepartment and to identify areas where theexperience of this patient group could be improved.

• Multi-agency management plans had beendeveloped for patients with mental health needswho were frequent attenders in the ED. Theseenabled staff to better support patients and hadresulted in a reduction of both ED attendances andadmissions to hospital.

• Complaints were listened to and acted upon. Therewas evidence that changes and improvements hadbeen made in response to complaints.

• All of the patients we spoke with during ourinspection commented very positively about the carethey received from staff. This was consistent with theresults of patient satisfaction surveys, which weremostly positive.

• Patients were treated with compassion and kindness.We saw staff providing reassurance when patientswere anxious or confused.

• Patients were treated with courtesy, dignity andrespect. We observed staff greeting patients and theirrelatives and introducing themselves by name androle.

• Patients and their families were involved as partnersin their care. We heard doctors and nurses explainingcare and treatment in a sensitive and unhurriedmanner.

• There was a strong, cohesive and well informedmanagement team who were highly visible andrespected.

• There was an effective governance framework.Information was regularly monitored to provide aholistic understanding of performance, whichincluded safety, quality and patient experience. Riskswere understood, regularly discussed and actionstaken to mitigate them.

• The emergency department had developed animprovement plan with clear milestones andaccountability for actions.

• Staff morale was mainly positive, although this hadbeen somewhat overshadowed by crowding and thepressures this placed on staff. Staff nevertheless feltvalued and supported.

• There were cooperative and supportive relationshipsamong staff. We observed exceptional teamwork,particularly when the department was underpressure.

• There was a strong focus on learning andimprovement. Clinical audit was well managed andused to drive improvement. Mistakes were openlydiscussed and learning acted upon. Staff at all levelswere encouraged to play their part in improvingpatient experience.




Are urgent and emergency services safe?

Requires improvement –––

We have rated this domain as requiresimprovement because:

• We had concerns about patient safety, particularly whenthe department was crowded, which was a regular andfrequent occurrence. Capacity was compromisedbecause ED attendances were increasing, both innumbers and in terms of patient acuity. Lack of patientflow within the hospital and in the wider communitycreated a bottle neck in the ED, creating pressures interms of space and staff capacity. This in turn increasedthe risk that patients may not be promptly assessed,diagnosed and treated.

• Crowding was compounded by an acute shortage ofstaff. There was an acute shortage of middle gradedoctors and there were particular concerns raised bymedical and nursing staff about medical cover at night.Consultants regularly worked longer hours to supporttheir junior colleagues and there were concerns aboutwhether this could be sustained. Analysis of demandpatterns indicated that more senior decision-makerswere required at night.

• The ED was not fully staffed with nurses. There were asignificant number of nurse vacancies and heavyreliance on bank and agency staff to fill gaps in the rota.When the department was crowded staff felt vulnerablebecause planned safe staff to patient ratios could not bemaintained.

• There was no senior (band seven) nurse employed tomanage each shift as recommended by the NationalInstitute for Health and Care Excellence (NICE).

• Support staff functions were not adequately resourced.Healthcare assistants performed housekeeping duties,doctors, nurses and managers moved patients, and thenurse coordinator was frequently occupied withadministrative duties.

• Crowding in the emergency department meant thatambulance crews were frequently delayed in handingover their patients.

• Patients were not always assessed quickly on theirarrival in the emergency department. Initial assessment(triage) often consisted of a verbal handover fromambulance staff to the nurse coordinator without a faceto face assessment of the patient.

• Record keeping was generally poor and we could not beassured that patients received prompt and appropriateassessment, care and treatment. This was notablyworse when the department was crowded. In particular,we were concerned about the recording of observationsand the calculation of early warning scores. Recordsindicated that patient observations were not alwayscarried out consistently or early enough and earlywarning scores, which may alert clinical staff that apatient’s condition is deteriorating, were notconsistently calculated.

• The mental health assessment room did not complywith safety standards recommended by the RoyalCollege of Psychiatrists.

• Staff were not provided with any mental healthawareness training as part of their mandatory training

However,

• There was openness and transparency about safety.There were few serious incidents but when theseoccurred, lessons were learned and well disseminatedthroughout the department.

• There were hourly board rounds undertaken by seniorclinicians in the department. This provided an overviewof the department’s activity and provided anopportunity to identify and communicate safetyconcerns to the site and trust management teams.

• Patient safety checklists had been introduced, whichprovided a series of time-sequenced prompts.

• There was a well-structured medical staff handoverwhere patients’ management plans and any safetyconcerns were discussed.

• The department was well equipped and equipment,including consumable items, was readily available,checked and maintained.

Incidents

• The trust reported no never events in urgent andemergency care between December 2015 andNovember 2016. Never events are serious patient safetyincidents that should not happen if healthcare providers




follow national guidance on how to prevent them. Eachnever event type has the potential to cause seriouspatient harm or death but neither need have happenedfor an incident to be a never event.

• In the same reporting period, seven serious incidentswere reported. These were as follows:

• December 2015: Delay to act on symptoms of severesepsis – a root cause analysis (RCA) took place, the casewas discussed at a mortality and morbidity (M&M)meeting, and learning was disseminated throughongoing education. All actions on the action plan werecomplete.

• February 2016: transfusion of blood intended foranother patient. A RCA was undertaken and actionsarising, including staff training and segregation andlabelling of blood, were completed.

• March 2016: Failure to recognise a seriously ill patient.Delayed clinical review (two hours, 35 minutes) andinappropriate transfer of a ventilated patient. A rootcause analysis took place and actions arising from thiswere completed, including simulation training.

• May 2016: Sudden deterioration of patient. Patientobservations were not recorded for a period of fourhours. A root cause analysis was undertaken. Actionsarising, including ongoing promotion of safety checklistand hourly board rounds, were completed.

• July 2016: Prescribing error leading to acute kidneyinjury. A RCA was conducted and actions, includingpersonal learning and reflection, and an email safetybriefing, were completed.

• August 2016: Delayed ambulance response, delayeddiagnosis in ED of subdural haemorrhage. A joint RCAwas conducted with the ambulance service. An actionplan was due to be completed in February 2017.

• November 2016: failure to escalate a deterioratingpatient. This incident was under investigation at thetime of our inspection.

• There was openness and transparency in safety in ED,where safety issues were regularly discussed. Thedepartment had a designated clinical governance leadwho led regular reviews of incidents. Incidents werediscussed at bi-monthly meetings and learning wasdisseminated in a number of ways:

• Message of the week: posters were displayed around thedepartment to draw staff’s attention to learning. Topicshad included: making reasonable adjustments forpeople with learning disabilities, mental health,

dementia or any condition where communication isimpaired, referral of appropriate patients to the fallsteam, pain asessment, safeguarding children screeningand sepsis treatment.

• Safety newletters were issued every two months.• Mortality and morbidity (M&M) meetings were held every

two months to review the care of patients who hadcomplications or an unexpected outcome. Learningpoints were shared with staff and real incidents wereused in simulation training. Mortality and morbiditytrends were reported in monthly emergency pathwayperformance reports.

• Quarterly missed radiology newsletters, combined withteaching and the development of new pathwaysinvolving trauma and orthopaedics, had led to adecrease in missed abnormal radiology over time.

• Theme of the fortnight: learning was disseminated totrainee doctors, in addition to ‘learning bites’ at eachearly/late shift handover.

• Staff told us they were encouraged to report incidentsand told us they received feedback when they did so.Staff did not routinely report concerns about crowdingand capacity/staffing levels, despite this being theirmost significant worry. They told us they saw no point inraising concerns. We were concerned that crowding hadbecome normalised. We were told this information wascaptured through the completion of hourly boardrounds in the department. Incidents were only reportedwhere capacity issues were linked to individual patientharm.

Duty of candour

• Staff were familiar with their responsibilities under theDuty of Candour regulation. Regulation 20 of the Healthand Social Care Act 2008 (Regulated Activities)Regulations 2014, was introduced in November 2014.This Regulation requires the provider to notify therelevant person that an incident causing moderate orserious harm has occurred, provide reasonable supportto the relevant person in relation to the incident andoffer an apology. Consultants provided examples ofwhere duty of candour had been applied. We sawpatients and their families had been contacted and keptinformed during the investigation of serious incidents.

Safety Thermometer

• The safety thermometer is used to record theprevalence of patient harm and to provide immediate




information and analysis for frontline teams to monitortheir performance in delivering harm-free care.Measurement at the frontline is intended to focusattention on patient harm and its elimination. Datacollection takes place one day each month. Data fromthe patient safety thermometer showed the trustreported no pressure ulcers, two falls with harm and nocatheter urinary tract infections in urgent andemergency care between January 2016 and January2017.

Cleanliness, infection control and hygiene

• The department was visibly clean and tidy. We sawcleaning in progress. There was one cleaner allocated tothe emergency department throughout the 24 hourperiod. However, nursing staff felt that overnightsupport was not always adequate because the cleaneralso covered the Acute Care Unit. We saw staff observedthe ‘bare below the elbow’ policy. The department wasequipped with adequate hand washing facilities. Staffwore protective clothing such as gloves and aprons.However, we observed nursing staff did not always cleantheir hands between patients.

• The department used evidence-based care bundles (aseries of actions/care elements) to prevent healthcareassociated infections when undertaking invasiveprocedures such as cannula and catheter insertion.Compliance with these safe systems was monitored ona monthly basis. Compliance in the period April toOctober 2016 was variable:

• Cannula insertion: compliance ranged from 50% to100% (average 71%).

• Urinary catheter insertion ranged from 75% to 80%.Results were only reported for three out of the sevenmonths.

• Hand hygiene compliance ranged from 70% to 100%.Results were only reported for three out of the sevenmonths.

• Compliance with the ‘bare below the elbow’ policyranged from 70% to 100%. Results were only reportedfor three out of seven months.

• There were two assessment/treatment rooms in majorswhere infected patients could be isolated and barriernursed to prevent the spread of infection.

Environment and equipment

• The emergency department was designed, laid out andequipped to keep people safe. However, the

department was frequently crowded and patientsqueued in the corridor and other non-clinical areas. Thismade it difficult to observe patients and to movetrolleys around. We noted on occasions that the accessto the resuscitation area was blocked by queuingpatients. One consultant told us: “The department wasdesigned to see 50,000 patients and it now sees 80,000patients.”

• Patients were not given bells so they could summonhelp from staff. We witnessed an elderly patient callingfor help but their call was not heard by staff. The patientwas trying to climb off their trolley in order to use thetoilet. We intervened and asked a nurse to assist.

• We had previously raised concerns about poor lines ofsight in both the adults’ and children’s waiting areas,which meant waiting patients were not adequatelyobserved. This meant that a deteriorating patient orinappropriate behaviour may go unnoticed. The heightof the reception desk meant that reception staff had alimited view of the main waiting area. This remainedunchanged.

• The children’s waiting area had appropriate restrictedaccess via the waiting room and the area was notoverlooked by the adults’ waiting area. However, thearea could be accessed via the majors/ minors areas.The area was not observed by staff to ensure thatanxious parents and children could summon attention.We frequently entered the children’s area and therewere no staff visible.

• We checked a range of equipment, includingresuscitation equipment in the ED. Resuscitation trollieswere all in order and appropriately stocked. Regularchecks were documented.

• The resuscitation area was well organised andequipment was well laid out and easily accessible. Wechecked consumable equipment, which was clean andin date.

• There were appropriate arrangements for thesegregation, storage and disposal of waste and we sawstaff comply with these safe systems.

Medicines (includes medical gases and contrastmedia)

• Medicines were appropriately stored in lockedcupboards or fridges. There was evidence that fridgetemperatures were regularly checked. Temperatureswere within the correct range at the time of ourinspection.




• Controlled drugs were stored appropriately and suitablerecords were kept. Controlled drugs are medicineswhich require extra checks and special storagearrangements because of their potential for misuse.

• Patients’ allergy status was consistently recorded onmedicine administration charts. This reduced the risk ofpatients receiving inappropriate medicines which mayhave a harmful effect.

Records

• Patients’ records in the emergency department weregenerally not well completed. Records were in paperformat and were scanned on to the hospital’s electronicsystem when patients were discharged or transferred toa ward. We looked at a sample of 20 records. They weremostly legible and written entries were signed anddated but in some cases the time of the entry was notrecorded. However, it was noted that the time ofassessment, triage, clinical investigations and dischargewere recorded on the clinical IT system.

• Patients’ observations (vital signs) and early warningscores were not completed consistently (see assessingand responding to patient risk below) so we could notbe assured that these assessments had taken place. Anewly introduced safety checklist, which was requiredfor all patients in the majors’ area, was not consistentlycompleted. This required the recording of a pain score,which we found was rarely recorded, even in caseswhere pain relief had been administered. There waslittle evidence that staff had assessed patients’ skinintegrity or offered them refreshments.

• Patients’ records were appropriately stored to enableeasy access for staff, whilst not being easily accessiblefor people who were not authorised to view them.However, records consisted of up to ten pieces of paperwhich were not always kept together, thus posing a riskof records going astray. For those patients who queuedin the corridor awaiting transfer to a ward, loose paperrecords were stored on the back of the patient’s trolley,and therefore were not secure.

• There were monthly audits of records relating to therecording of observations of vital signs and NationalEarly Warning Scores (NEWS). NEWS is a recognisedearly warning score tool to assess patients’ risk and theirneed for physical observations. Documentation auditsformed part of the trust’s audit plan to ensure regularmonitoring.

Safeguarding

• There were processes in place for the identification andmanagement of adults and children at risk of abuse(including domestic violence and female genitalmutilation). Staff understood their responsibilities andwere aware of safeguarding policies and procedures.There was a safeguarding lead nurse in the ED.

• There were identifiers visible on patients’ records wherepatients were known to the service due to previoussafeguarding concerns. Staff could then accessmanagement plans to support patients’ ongoing careand treatment.

• The department was meeting most of the SafeguardingChildren’s Standards produced by the College ofEmergency Medicine’s Clinical Effectiveness Committee:

• Training records showed that in October 2016, 82.9% ofmedical staff had completed level 2 safeguardingtraining for adults and children. Nursing staff performedbetter, with 96.5% completing level 2 safeguardingadults training and 90.1% completing level 2safeguarding children training.

• The trust told us that all consultants and middle gradedoctors had received level 3 child protection training.

• The department had access to a senior paediatric andsenior emergency medicine opinion 24 hours a day forchild welfare issues.

• The patient record system identified previous childattendances in the last 12 months so that staff would bealerted to possible safeguarding issues.

• Frequent attenders (more than three attendances in lastyear with different conditions) were notified to the localsafeguarding children services.

• Child attendances were notified to GPs, health visitorsand school nurses.

• We were told that all skull or long bone fractures inchildren under one year were discussed with a seniorpaediatric or ED doctor during their ED attendance.

• At our last inspection we were concerned that there wasno ‘safety net’ to ensure that child safeguarding referralrates were appropriate. There was a health visitor liaisonteam who attended the ED every few days to checkreferrals but they did not check all child attendances tosee if any had been missed. In response to our findingsthe department strengthened processes to include areview of all child attendances by a children’s’safeguarding nurse and completion of any missedpaediatric liaison forms. In addition, they checked adult




attendances relating to overdoses, deliberate self-harm,drug or alcohol abuse and domestic abuse to see if theyhad any children and if so, ensure that paediatric liaisonforms were completed and the necessary authoritiesinformed.

Mandatory training

• Staff were required to complete mandatory training,including refresher training in 12 essential subjects. Thetrust’s target for completion of mandatory training was90%. Whist there were differences between nursing andmedical staff, the overall compliance for all subjects wasapproximately 90%.

Assessing and responding to patient risk

• The trust used a recognised triage system (Manchester)in ED for the initial assessment of all patients. Guidanceissued by the College of Emergency Medicine (TriagePosition Statement dated April 2011) states that a rapidassessment should be made to identify or rule out life/limb threatening conditions to ensure patient safety.This should be a face-to-face encounter which shouldoccur within 15 minutes of arrival or registration andassessment should be carried out by a trained clinician.This ensures that patients are streamed or directed tothe appropriate part of the department and theappropriate clinician. It also ensures that serious orlife-threatening conditions are identified or ruled out sothe appropriate care pathway is selected.

• Staff used a mental health risk assessment tool toestablish the level of risk associated with patientspresenting with mental health needs.

• Trust-wide, the median time from arrival to initialassessment (emergency ambulance cases only) wasworse than the England average for the 12 months fromDecember 2015 to November 2016. In November 2016the median time to initial assessment was 12 minutes,compared with the England average of seven minutes.During the week of our inspection performance againstthe 15 minute standard for patients brought byambulance to the GRH ranged from 46.7% to 75.9%.Since raising our concerns the trust have introduced atriage nurse and receptionist at the point of entry to theemergency department to enable immediateambulance handover and triage assessment.

• Patients arriving by ambulance were triaged by themajors’ nurse coordinator. We observed that in most

cases there was no face to face assessment of patientsand the triage consisted of a handover from ambulancestaff, who were then directed to transfer the patient to aclinical area or to the corridor.

• We followed a patient who had fallen from a height andhad been brought into the ED by ambulance staff. Theambulance crew, in their handover to the nursecoordinator, advised it was unclear whether the patienthad lost consciousness during their fall. The coordinatorcould not see the patient as they were in the corridoraround the corner. They directed the ambulance crew totransfer the patient to wait in the corridor forassessment. There was no corridor nurse allocated atthat time.

• We were concerned that following this handover,patients often waited too long before observations ofvital signs were taken and an early warning scorecalculated. The emergency department used thenational early warning score (NEWS) tool to identifyseriously ill and/or deteriorating patients. NEWS scoresare calculated by measuring and grading vital signs suchas blood pressure respiratory rate and temperature. Ahigh score may indicate the need for more frequentobservations or immediate intervention. All patients inthe majors’ area were supposed to have their vital signsmeasured and a NEWS score calculated on an hourlybasis.

• We looked at a sample of 20 records and found thatpatients’ observations were not completed with therequired frequency and early warning scores were notconsistently calculated. Some patients did not havetheir observations recorded for periods of three to fourhours.

• Compliance with the use of the early warning score toolwas monitored monthly. Results ranged from 50% to100% (an average of 85%) in the 10 months February toNovember 2016. The monthly audit also tested whetherappropriate actions were taken in response to earlywarning signs. Performance was similarly variable, withresults ranging from 10% to 100% (an average of 60%).

• The trust had introduced an emergency departmentsafety checklist (known as SHINE) in June 2016. Thedocumentation prompted staff to undertakeobservations, tests and treatments in a time-basedsequence. Compliance with this new system was being




monitored via monthly audits. Whilst this was improvingover time, the system was not well embedded in use.Performance ranged from 13% in September 2016 to35% in November 2016.

• Of the 20 records we checked, only one had a safetychecklist fully completed and some had not beencommenced. In particular, the checks required in hourstwo onwards were not well completed. We saw littleevidence for example that patients’ skin was checked forpressure ulcers or that patients were offered food anddrink.

• Self-presenting patients were assessed on arrival by atriage nurse, following their registration at the receptiondesk. The trust monitored the time that patients waitedfor their initial assessment. During the week of ourinspection, performance against the 15 minute standardfor self-presenting patients ranged from 40.2% to 89.3%.

• Receptionists in the minors’ area told us they used theirjudgement and experience to recognise a seriouslyunwell/injured patient who needed immediate clinicalattention. There was no written guidance about ‘redflag’ conditions and staff confirmed they had receivedno training to recognise red flags. They told us theysummoned help either in person or by phone. TheRCEM Triage Position Statement states: “Some elementsof the triage process, such as initial recognition ofurgency, may be undertaken by an unregistered healthworker, e.g. reception staff using clearly defined “redflags” which identify urgency. For this reasonnon-registered health care workers in emergencysettings should have basic training in red flagpresentations and how to call for immediateassistance…”.

• There was insufficient observation and monitoring ofpatients in the children’s waiting room. Children werenot supervised as recommended in Health BuildingNote (HBN) 15-01 which states “the waiting area shouldbe provided to maintain observation by staff.” We hadraised this at our previous inspection but the situationremained unchanged. We frequently entered thechildren’s waiting area during our inspection and therewere no staff visible.

• The trust monitored ambulance turnaround times in theemergency department. At GRH, performance showedan upward (worsening) trend) between January 2016and December 2016. In December 2016, 1,653 journeyshad a turnaround time of 30 minutes or more and 202had a turnaround time of 60 minutes or more.

• There was an hourly ‘safety board round’ conducted bythe majors’ coordinator and the consultant (or middlegrade doctor) in charge. This was an opportunity toidentify any safety concerns and update the escalationstatus of the department. The escalation status (definedin the department’s escalation policy) described thedepartment’s ability to provide safe, timely and efficientcare to patients. Factors affecting this ability includedsurges in activity, insufficient staff and a lack of patientflow within the hospital. There was a guide for shiftleaders for managing escalation, which outlined theprocesses, including communication to alert the sitemanagement team of the department’s status.

• There was a doctors’ handover at 1pm every day,attended by all grades of staff, where patients’ risks andmanagement plans were discussed.

• There was a sepsis screening tool and care pathway inuse and the safety checklist included a prompt toensure staff considered sepsis. Staff told us thatambulance crews pre-alerted ED staff when an incomingpatient was suspected to have sepsis. The patient wouldbe taken directly to the resuscitation area on arrivalwhere the screening tool would be activated. Where nopre-alert took place or where the patient self-presented,the first opportunity to identify possible sepsis was attriage. The sepsis screening tool prompted staff toconsider sepsis if the patient early warning score was 3or more.

• The emergency department measured performanceagainst the standard which required applicable patientsto be screened on arrival. In the period July toNovember 2016 performance was between 96% and98%. The department also measured the time thatpatients were treated with antibiotics. The RCEMstandard is that 50% of patients should receiveantibiotics within one hour and 100% within four hours.Between July and November 2016 compliance with theone hour target increased from 41% to 62% with 83%receiving antibiotics within two hours and 100% by 4hours.

• We retrospectively followed the pathway for a patientwho attended the ED during our visit. They were triaged15 minutes after their arrival and a sepsis screen wascompleted within 30 minutes. They were reviewed by adoctor after 40 minutes and received antibiotics withinone hour and 20 minutes.

• We saw one patient who had been brought to ED byambulance and the ambulance crew had noted a high




early warning score (6) and had highlighted thepossibility of sepsis. The patient had no observationsrecorded for over two hours after their arrival and asepsis screen was not undertaken. Lactate wasmeasured nearly three hours after the patient’s arrival.RCEM recommends that all patients with physiologicalderangement, an elevated NEWS score above triggerthreshold, or with clinical suspicion of infection to bescreened for the presence of sepsis, severe sepsis orseptic shock and to have a serum lactate within 30minutes of arrival. A senior nurse told us there wereoften delays in identifying patients with sepsis asobservations were often delayed due to a shortage ofnursing staff.

• Patients with mental health problems were riskassessed and prioritised using a mental healthassessment pro forma. In the RCEM Mental Health in theED audit 2014-15 the ED had performed poorly. Ofparticular concern was the score for the fundamentalstandard which requires that a risk assessment is takenand recorded in the patient’s clinical record. The EDscored 49% against the RCEM standard of 100%. Actionstaken to improve this included the provision of trainingin the use of the documentation at medical staffinduction. The department was also training emergencynurse practitioners to undertake risk assessments. Therewere plans to re-audit this in July 2017. We reviewedfour records for patients who had attended ED withmental health problems and found the mental healthproforma had been used and completed appropriately.

• Crowding in ED was a serious and ongoing risk, whichwas identified on the department’s and the trust’s riskregisters. There was a trust Escalation and patient flowpolicy, within which there was an emergencydepartment escalation policy, including a guide for shiftleaders; Maintaining safety in the emergencydepartment. Shift leaders completed hourly boardrounds where they allocated scores against definedtrigger points, including the number of patients in thedepartment, space available in majors and resuscitationand the number of ambulances queuing.

• There were a series of action cards for medical andnursing staff to follow in the event of escalation. Actionsincluded reallocating staff, requesting additional staffand diverting patients to other EDs.

• There was a system in place to ensure that significantradiological pathology was not missed. All radiologyreports were reviewed by a consultant the next working

day and patients were notified if anything had beenmissed and were asked to re-attend the department.Funding had been secured for a project, led by an EDconsultant, to work with radiology to monitor and learnfrom missed pathology. Learning was disseminated viateaching sessions, in addition to bi-monthly newsletters.

Nursing staffing

• The emergency department was not consistently staffedto planned levels of nursing staff and even when staffedto planned levels, safe staff to patient ratios could notbe maintained in all areas of the department,particularly in times of crowding.

• At November 2016, the trust reported a vacancy rate of14.7% at GRH. The matron told us that, following ourlast inspection, the department had reviewed staffinglevels and skill mix in order to align staffing withpatterns of demand. The nursing establishment hadbeen increased by one nurse on the late shift. Thematron told us that in majors a staff to patient ratio ofone registered nurse to three patients was the plannedstaffing level, although one to four was consideredacceptable. Due to the ongoing vacancy factor anddifficulties with recruitment there were regular shortfallsin the rota. These were regularly filled by temporary(bank and agency) staff. Agency staff were block-bookedto improve familiarity and continuity. We were told thatplanned staffing levels were achieved on most shifts.When we looked at the staffing allocation for the threeweeks leading up to our inspection, we found thatwhilst some shifts were not fully filled, every shift hadbetween one and four agency staff employed.

• There was a nurse allocated on each shift to care forpatients queuing in the corridor; however this was notconsistently maintained. We noted that one nurse wasallocated to look after patients in the resuscitation area.However, when there were more than two patients inthis area, a nurse from majors or the corridor wasmoved there. On 25 January we noted there were fourto six patients on the corridor with no corridor nurseallocated over a period of 15 minutes. After 15 minutes anurse was moved to the corridor, by which time theyhad ten patients to care for. Staff told us they werefrequently asked to care for too many patients. Onenurse told us that they had on one occasion beenresponsible for 17 patients.

• At our last inspection the trust was struggling to appointsenior nurses to undertake the floor manager role. This




continued to be a challenge and this position remainedunfilled. This put tremendous pressure on the nursecoordinator and the matron was frequently providing‘hands-on’ support. Guidance issued by NICErecommends that a senior (band seven) nurse should bedeployed to manage each shift in emergencydepartments.

• There was one nurse allocated to care for patients onthe corridors, when all cubicles were in use. This wasfrequently insufficient when the department wascrowded. During our inspection there were regularlybetween four and ten patients being cared for on thecorridors, in addition to patients waiting in the subwaiting area. Staff were pulled from other areas of thedepartment, including nursing staff from thedepartment’s administrative function. Additional agencystaff were also deployed to assist. Nursing staff told usthey felt “vulnerable” at times due to the number ofpatients they were expected to care for, sometimes upto ten. They were worried about not being able toprovide a safe level of care. Having raised theseconcerns with the trust at the time of the inspection,they have since informed us that a review of proceduresand practice in respect of would be suitable to be caredfor in the corridor, when demands require it, had beenundertaken in order to ensure patients with morecomplex needs were identified and cared for in a cubicleas soon as possible.

• There was not a dedicated paediatric trained workforcein ED; however, the department was taking steps toupskill adult-trained nurses in order to meet thestandards set out in the Royal College of Paediatrics andChild Health Standards for Children and Young People inEmergency Care Settings (2012). This guidance identifiesthat there should always be a registered children’s nurseon duty in ED or trusts should be working towards this.The guidance recognises this is often not achievable butstates “nursing staff caring for sick children requirecompetence in emergency nursing, includingorganisational and clinical skills, and in the care ofchildren.” Nursing staff should be trained to at leastPaediatric Intermediate Life Support (PILS) or PaediatricLife Support (PLS) level.

• The A&E risk register highlighted the risk of“inappropriate care of children by adult-qualifiednurses”. This was graded a moderate risk. Actions tomitigate the risk included the development of a rollingprogramme on paediatric illness and it was recorded

that “all registered nurses in ED undergo detailedinduction, ongoing training and paediatric resuscitationtraining to mitigate any risk.” The department employedone registered children’s nurse. All nurses received a halfday’s training (a general introduction to paediatrics) aspart of their induction. Training records showed thatapproximately 20% of adult trained nurses hadcompleted an acutely unwell/injured child course, witha further 6% due to start or complete the course in 2017.Approximately 60% had completed PLS or advancedpaediatric life support training.

Medical staffing

• In November 2016 there was a vacancy rate of 18.5% inurgent and emergency care trust-wide. Many of themedical staff we spoke with raised concern aboutmedical staffing at night. The ED risk register highlightedthe “inability to provide safe and timely clinical care dueto a lack of 24 hour middle grade doctors”. The registerwas updated in August 2016 stating “demand andcapacity work completed…….additional consultant,junior and ENP posts approved August 2016 andrecruitment in progress; rota being developed to reducemiddle grade gaps.”

• The department was able to achieve the target ofproviding a minimum of an ST4 (specialist registrar year3) or above in the department 24 hours a day, sevendays a week. However, this was challenging due ashortage of middle grade doctors. Consultants worked8am to midnight five days a week and 24-hour coverwas provided two days per week, with consultants“acting down” to fill middle grade gaps in the rota.Concerns were expressed by both medical and nursingstaff about the lack of senior decision makers at night.They told us that when there was only one senior doctoron duty (after midnight) they may be required to spendmost of their time caring for patients in the resuscitationarea. This left relatively junior medical staff to care for allother patients. We were told that, in addition to workingsome nights, consultants regularly worked beyondmidnight to support their junior colleagues when thedepartment was very busy. There were concernsexpressed about how long this could be sustained.Concerns regarding sustainability and demands formedical staff are being addressed through a workforcestrategy. There was dedicated Consultant workforcelead who actively took part in strategy and recruitment.




Since the inspection the trust have advised us they areactively recruiting a further consultant and haveappointed a physician associate to commenceSeptember/October 2017

• During our inspection the department experienced avery busy afternoon and night, with between 50 and 70patients in the department. The consultant rostered tobe on duty until midnight did not go home until 8am thenext morning. The specialty director joined them at9pm, remaining in the department until 5.30 am.Despite the department being fully staffed (to plannedlevels) in the afternoon and additional medical staffhelping at night, the department reported they hadstruggled to keep up with the workload. At one pointthere were waits of three hours for patients to bereviewed by a doctor. The department had undertaken adetailed analysis of demand and capacity and hadbenchmarked their staffing levels with othercomparable emergency departments. Both of thesepieces of work supported the case for additionalmedical staff and/or re-modelling of the service,although the status of this analytical work was unclear.

• There were structured handovers between medical staffat the beginning of each shift. We observed the 8amhandover, which was well attended. There was astructured format which was clearly well practised andunderstood. All patients in the department werediscussed and action plans were agreed. There wasclear delegation of tasks and responsibilities for theforthcoming shift.

• All consultants and registrars were trained in advancedpaediatric life support. Junior doctors received trainingon induction which covered safeguarding and the sickchild. There were also written guidelines on paediatriccare.

• There were two ED consultants dedicated to paediatrics.One was responsible for developing protocols andaudit, while the other took the lead on children’s’safeguarding matters. They had regular meetings withpaediatrics and attended the paediatric risk meeting.

Other Staffing

• As noted above, the nurse coordinator was notsupported by a floor manager. We noted also that theydid not have the support of a dedicated receptionist inmajors. This position was established to support thecoordinator during the late shift. Their duties includedregistering patients, answering the telephone, patient

transfers and transport and scanning patients’ records.The position was not filled on any of the late shiftsduring our inspection. As a result the coordinator wasfrequently occupied with these administrative duties.

• Porters were employed in ED in overlapping shiftsthroughout the 24 hour period. This service was sharedwith the Acute Care Unit and, in effect, there was mostlyone porter available for the department. There was ahospital-wide patient transfer team, staffed by twohealthcare assistants, who could be called upon toassist but at times this was clearly not sufficient. Wefrequently saw nursing and managerial staff movingpatients. On the day of our unannounced inspection wesaw doctors, nurses, and managers moving patients.Whilst this demonstrated commendable commitmentand teamwork, it highlighted the inadequacy of thissupport function. The patient transfer team was staffedby only one staff member that day so ED staff frequentlyaccompanied them. Staff had raised concerns about ashortage of porters at our previous inspection. Abusiness case had been submitted for additional staffbut this had been turned down for financial reasons.

• Two healthcare assistants were employed on each shift.Senior staff told us they were responsible for cleaningand re-stocking the department each morning but theywere frequently occupied serving breakfast to patientswho had been in the department overnight becausethere were no housekeeping staff employed.

• There was one cleaner employed in the department.Nursing staff did not consider this was adequate,particularly at night when the staff member was sharedwith the ACU. This meant that nursing staff had toundertake cleaning duties.

Major incident awareness and training

• There was a major incident plan, including actionscards, which had been recently reviewed and wasup-to-date. There was a training DVD available on thedepartment’s intranet: Initial Operational Response,produced by the Home Office with advice and guidanceon managing incidents where patients werecontaminated with hazardous materials (HAZMAT) or achemical, biological, radiological or nuclear (CBRN)incident.

• Staff in the emergency department told us they felt safe.All staff carried personal alarms, which, when activated,




sounded throughout the department. Staff wereprovided with conflict resolution training; however only74.3% of medical staff and 79.6% of nursing staff hadcompleted this.

Are urgent and emergency serviceseffective?(for example, treatment is effective)

Good –––

We have rated this domain as good because:

• People’s care and treatment was planned and deliveredin line with current evidence-based guidance andstandards.

• There was a range of recognised protocols andpathways. Compliance with pathways and standardswas monitored through participation in national audits.Performance in national audits was mostly in line withother trusts nationally. There was evidence that auditwas used to improve performance, for example in thetreatment of sepsis.

• Nursing and medical staff received regular teaching andclinical supervision. Staff were encouraged andsupported to develop areas of interest in order todevelop professionally and progress in their careers.

• Care was delivered in a coordinated way with supportfrom specialist teams and services. Specialist teamssuch as the stroke team, the discharge assessmentteam, the specialist nurse for older people, the mentalhealth liaison service and the alcohol liaison serviceworked closely and collaboratively with the emergencydepartment.

• Staff demonstrated knowledge and understanding oftheir responsibilities in relation to the Mental CapacityAct 2005 and consent.

• Information needed to deliver effective care andtreatment was available to staff involved in patients’ongoing care when they were discharged or transferredto another service.

However:

• Pain was not always promptly assessed and managed.• We could not be assured that patients’ nutrition and

hydration needs were consistently assessed or met.

Evidence-based care and treatment

• Care and treatment was delivered using recognisedclinical guidelines, for example, National Institute forHealth and Care Excellence (NICE) guidelines and theRoyal College of Emergency Medicine’s (RCEM) ClinicalStandards for Emergency Departments. There wereclear pathways, supported by proformas for themanagement of conditions such as stroke and sepsis.We saw evidence in patients’ records that staff werefamiliar with these pathways and that they werefollowed.

• We observed the conscious sedation of a patient in theresuscitation area, which was undertaken in accordancewith standards produced by the Royal College ofAnaesthetists.

• We observed prompt, efficient assessment and referralof a stroke patient.

• Compliance with pathways and standards was auditedon a regular basis and education took place tocontinuously improve knowledge of, and compliancewith, good practice.

Pain relief

• When we inspected the emergency department inMarch 2015 we found that patients did not consistentlyreceive prompt pain relief. The department hadperformed poorly in relation to pain management in theRoyal College of Emergency Medicine audits in relationto renal colic (2012) and fractured neck of femur(2012-13).

• An internal re-audit of the management of fracturedneck of femur was undertaken in 2016 and thedepartment continued to score poorly in relation to theassessment and management of pain. The audit foundthat pain assessments were not consistently recorded attriage (this was consistent with our findings during ourinspection) and many patients were not reviewed by adoctor within one hour, which delayed painmanagement. It was concluded that workload was amajor contributing factor.

• The department had delivered teaching sessions tomedical and nursing staff to raise awareness andimprove performance. We observed that patients’ painrelief was discussed at the medical staff handovermeeting.

• The new safety checklist contained hourly prompts toassess and reassess pain; however, these checklistswere not yet embedded in practice and we found theywere not consistently completed.




• An audit of pain relief in children reported to themortality and morbidity committee in August 2016reported that the emergency department at GRH wasnot meeting RCEM standards.

Nutrition and hydration

• We noted in patients’ records that staff rarely recordedthat food and drink had been offered to patients whohad been in the department for more than two hours.The new safety checklist included prompts at two, threeand four hours but in the sample of records wereviewed, the checklist was rarely completed over thistime so we could not be assured this was givenadequate attention. We reviewed records of patientswho had been in the department for up to 13 hours andsaw no evidence of refreshments being offered orprovided. There were visual reminders about nutritionand hydration displayed in cubicles. Whiteboards weresupposed to be used to record when a patient had lasteaten or drank. These were not completed. During ourinspection, we were asked on a number of occasions bypatients if they could have a drink and we relayed thesemessages to the nursing staff. One patient, who waswaiting to be seen in the corridor, told us they wereanxious about obtaining food because they werediabetic. This was not identified on their records. Weinformed a member of staff who assured the patientthat they would arrange for a sandwich to be provided.

Patient outcomes

• Information about patient outcomes was routinelycollected and monitored. The trust participated innational RCEM audits and internal audits so they couldbenchmark their practice and performance against bestpractice and other emergency departments. There wasa designated consultant audit lead for the department,who oversaw the audit programme and the completionof action plans. Overall, the trust performed in line withother trusts nationally.

• In the RCEM 2015-16 audit of vital signs in children, GRHwas in the top quartile for one of the six measures and inthe lower quartile for three of the six measures. Anaction plan had been developed, although actions wereincomplete at the time of our inspection.

• In the 2015-16 RCEM audit for venousthromboembolism (VTE) Risk in Lower LimbImmobilisation in Plaster Cast, Gloucestershire Royalperformed:

• In the lower quartile for the measure ‘If a need forthromboprophylaxis is indicated, there should bewritten evidence of the patient receiving or beingreferred for treatment’.

• Between the upper and lower quartiles for the measure‘Evidence that a patient information leaflet outlining therisk and need to seek medical attention if they developsymptoms for VTE has been given to all patients withtemporary lower limb immobilisation’. An action planwas developed in response to the audit findings. Actionsincluded teaching to medical staff and emergency nursepractitioners, the introduction of a plaster pack whichwould serve as an aide memoire and personal feedbackto ENPs.

• In the 2015-16 Procedural Sedation in Adults audit GRHwas in the upper quartile compared to other hospitalsfor five of the seven measures. The remaining twomeasures were between the upper and lower quartiles.

• The trust was better than the England average forstandard which requires the percentage of patientsre-attending the department unplanned within sevendays to be less than 5% averaging between 1.3-1.8% ofpatients.

Competent staff

• The department had two practice development nurseswho were responsible for planning, coordinating anddelivering in-house training.

• There was a programme of ED competency basedtraining and professional development training for eachgrade of nursing staff. Each staff member maintainedtheir own training record which was overseen by theirmanager. The matron told us that all nursing staffreceived seven to eight days training per year, althoughevidence of this was not provided.

• Junior medical staff told us they were well supportedand had access to regular training, including regular‘learning bites’ at daily handover meetings. There wasprotected one-to-one time for one hour each monthwith consultants, where the subject was nominated bythe junior doctor.




• Appraisal rates for the unscheduled care divisiontrust-wide were as follows:

• Healthcare Assistant staff: 83%• Other, including administrative and clerical staff: 87%• Medical staff: 83%• Nursing staff: 77%

• The General Medical Council (GMC) reported in their2016 regional review that doctors in training hadcommented favourably about the willingness of EDconsultants on the floor to teach. They also commentedpositively about multidisciplinary teaching, witheducational sessions provided by mental healthprofessionals and physiotherapists, and opportunitiesfor simulation training. In the 2016 GMC survey therewas positive overall satisfaction fed back by foundationyear 1 doctors. Foundation year 2 doctors and coretrainee doctors expressed some concerns about clinicalsupervision, particularly at night, handover andworkload.

Multidisciplinary working

• Staff, teams and services mostly worked well together todeliver effective care and treatment. There was a goodrelationship with the mental health trust and regularmultidisciplinary meetings with the ED, mental healthtrust and the police to discuss regular attenders.

• There was an Assisted Discharge Service provided by theBritish Red Cross from Monday to Friday from 10.30amto 10.30 pm. The team provided a transport andresettlement service for people in vulnerablecircumstances to ensure their discharge from ED or theacute care unit was safe. Patients were offered twohours’ support, which might include making sure theirhome was warm and safe and that they had food in thehouse. There was also a night sitting service available.The service was valued by ED staff but the departmentwas not able to provide the volunteers with apermanent office base. They used the department’sseminar room when it was not occupied but we sawthey were frequently asked to vacate this area.

• There were two primary care pilots in the emergencydepartment, commissioned by the local clinicalcommissioning group. In minors, self-presentingpatients attending the emergency department onweekdays between 10am and 10pm were greeted by aclinical navigator (a nurse employed by the localambulance service) who streamed appropriate patients

(those with minor illnesses) to see a GP or an advancednurse practitioner. There was also a GP based in majorsfrom midday to 10pm who identified patients who couldpotentially be managed in the community. The GPworked closely with the integrated discharge team.

• ED staff reported that they were well supported by somespecialties; however, there was a general feeling thatthere was a lack of ownership of the four hour ED targetin the rest of the hospital. There were frequentdifficulties in transferring patients from ED toappropriate beds once the decision to admit had beenmade. On the day of our unannounced inspection therewere 22 patients in the emergency department waitingfor beds at 8am. During our visit we saw patients whohad been in the department for up to 13 hours. This exitblock was a source of immense frustration amongstclinicians in the emergency department and there was afeeling expressed by some that more could be done bythe rest of the hospital to support the emergencydepartment.

• At our last inspection we were told that a performancemeasure had recently been implemented wherebyspecialties were required to accept admissions from EDwithin 30 minutes of the decision to admit. This wasmonitored by daily analysis of breaches. At thisinspection we were told that although delays inspecialist review were still monitored and reported on inweekly breach meetings and at the monthly emergencycare board, internal professional standards had onlyrecently been published. It was reported in theDecember 2016 emergency care pathway report that theimplementation of internal professional standards forall specialties, which was an action of one of theemergency care board’s work streams, was “not on trackto deliver”. It was reported that the work stream hadmanaged to agree seven of the ‘top ten’ standards withkey stakeholders. The report went onto say, “thereremains some concern among the clinical bodyregarding some of the wording of the standards but thechief executive has asked the work stream to simplydefine the standards we are aspiring to achieve in orderto establish the improvement actions required to deliverthem”.

Seven-day services

• There was senior medical staff presence in the ED sevendays a week.




• Pharmacy services were available Monday to Fridayonly, although there was a pharmacist on-call out ofhours. Senior staff in the emergency department wereunhappy about the lack of service over the weekend.

• Radiology was available seven days a week.• Mental health liaison was available seven days a week;

however support for children and young people wasreduced at weekends. Specialist support for patientspresenting with drug or alcohol misuse was notavailable at weekends.

• Attendance/admission avoidance initiatives, includingthe primary care service in ED, the older people’sassessment and liaison service and ambulatoryemergency care were currently only provided Monday toFriday.

Access to information

• Information needed to deliver effective care andtreatment was available to staff involved in patients’ongoing care when they were discharged or transferredto another service.

• Patients admitted to inpatient wards from theemergency department had their records scanned ontothe hospital’s electronic system before they weretransferred to the ward. For those patients who weredischarged from the emergency department, anelectronic discharge summary was generated and sentto the patient’s GP.

• There was a bespoke IT system which was real-time andallowed tracking of patients through the department.The status of both of the trust’s EDs could be viewed oneither site, thus enabling an overview of the workload.The system also allowed for statistical analysis andreporting of activity.

• A new patient record system had been introduced inDecember 2016. Staff described numerous difficultieswith this system, which were time consuming anddistracting.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

• We observed patients being asked for verbal consent.Doctors and nurses explained things to patients simply,checked their understanding and asked permission toundertake examinations or perform tests.

• The trust reported that at 31 October 2016 MentalCapacity Act 2005 (MCA) awareness training had beencompleted by 86.7% of all staff within Urgent andEmergency Care.

• Deprivation of Liberty Standards (DoLS) Awarenesstraining had also been completed by 86.7% of all staffwithin Urgent and Emergency Care. However, thecompletion rate for both modules fell below the trusttarget of 90%.

Are urgent and emergency servicescaring?

Good –––

We rated this service as good because:

• All of the patients we spoke with during our inspectioncommented very positively about the care they receivedfrom staff. This was consistent with the results of patientsatisfaction surveys, which were mostly positive.

• Patients were treated with compassion and kindness.We saw staff providing reassurance when patients wereanxious or confused.

• Patients were treated with courtesy, dignity and respect.We observed staff greeting patients and their relativesand introducing themselves by name and role.

• Patients and their families were involved as partners intheir care. They told us they were kept well informedabout their care and treatment. We heard doctors andnurses explaining care and treatment in a sensitive andunhurried manner.

Compassionate care

• We observed staff interacting with patients and theirrelatives in a respectful and considerate manner. Weobserved staff greeting patients and their relatives andintroducing themselves by name and role. We noted,however, that not all staff wore name badges.

• Patients and relatives we spoke with told us staff werecaring, compassionate, friendly and engaging. We sawstaff providing reassurance to patients when they wereanxious or confused.

• We witnessed a staff member speaking with an injuredchild. They distracted them by asking about theirinterests, and reassured them about having an x-ray.




• Patients’ privacy and dignity were respected wherepossible. However, at times this was challenging due tocrowding. Patients frequently queued in the corridorbecause there were no cubicles available. Staff tried tokeep one side room free so that patients requiringclinical tests, private conversations or toileting weregiven some privacy. However, this area was not alwaysavailable. We observed a patient who was cared for inthe corridor for a number of hours, despite sufferingfrom diarrhoea.

• The trust used the friends and family test to capturepatient feedback. Response rates had increasedsignificantly since the introduction of a new digitalmethodology and in September 2016 was 27.5%.However, the percentage of respondents who wouldrecommend the service started to decline in September2016. In December 2016, 78% of responses werepositive, compared with and England average of 86%.

• We spoke with approximately 20 patients and relatives.Whilst their feedback was not entirely positive - due tolongs waits and a lack of comfort and privacy on thecorridor - they were very positive about the staff and thecaring attitude they displayed. Many patients expressedadmiration and sympathy for staff working in such abusy and pressurised environment.

Understanding and involvement of patients andthose close to them

• We witnessed doctors explaining treatment plans topatients and their relatives. They took time to checktheir understanding and asked them if they had anyquestions. Relatives told us they felt they had beeninvolved in the decision-making process about thetreatment of their family members.

• The nurse coordinator received numerous telephonecalls from relatives enquiring about their loved ones.They dealt with these in a sympathetic manner andoften took the phone to the patient so that they couldspeak with their relatives.

Emotional support

• We witnessed staff speaking compassionately withpatients (and their relatives) who had presented withserious (potentially life-changing) illness. They spokesensitively about treatment options and prognosis.During a medical staff handover meeting a doctor spokeabout the needs of a relative who was finding it difficultcoming to terms with their relative’s diagnosis.

Are urgent and emergency servicesresponsive to people’s needs?(for example, to feedback?)


We have rated this service as requires improvementbecause:

• The trust was consistently failing to meet the standardwhich requires that 95% of patients are discharged,admitted or transferred within four hours of arrival atthe emergency department.

• Patients frequently spent too long in the emergencydepartment because they were waiting for an inpatientbed to become available. Lack of patient flow within thehospital and in the wider community created abottleneck in the emergency department, causingcrowding.

• Crowding meant patients frequently queued in thecorridor, where they were afforded little comfort orprivacy. When the department became congested,relatives had to stand because there was insufficientseating.

• Patients with mental health needs were not alwayspromptly assessed or supported, particularly at nighttime when there was no mental health liaison service.Adolescents who had self-harmed did not receive aresponsive service and were frequently inappropriatelyadmitted while awaiting specialist assessment andsupport.

• There was a lack of an appropriate welcoming space forpatients with mental health needs.

However:

• The service had a number of admission avoidanceinitiatives in place to improve patient flow. Theseincluded the integrated discharge team who proactivelyidentified and assessed appropriate patients who maybe able to be supported in the community rather thanadmitted to the hospital.

• We saw evidence that complaints were used to driveimprovement.

• The emergency department had recently developed ateam known as the Gloucestershire elderly emergencycare (GEEC), championed by an ED consultant. The aim




was to raise awareness of the issues faced by frail elderlypatients in the emergency department and to identifyareas where the experience of this patient group couldbe improved.

• Multi-agency management plans had been developedfor patients with mental health needs who werefrequent attenders in the ED. These enabled staff tobetter support patients and had resulted in a reductionof both ED attendances and admissions to hospital.

Service planning and delivery to meet the needs oflocal people

• The trust was working closely with commissioners toidentify system-wide strategies to improve patient flow.

• The ED was accessible. There was parking availableclose to the department and there was a covereddrop-off zone. The helipad was directly opposite the EDwith quick and easy access to the ambulance entrance.

• Facilities and premises were not wholly adequate. Thedepartment was frequently crowded. Patients queued inthe corridor, some on arrival in the department, otherswhile waiting to be seen, and some while waiting to betransferred to a ward. The trust monitored and reportedon the average number of patients in the ED corridor perday. In November 2016 the average at GRH was 86.

• On the day of our unannounced inspection there wassignificant pressure on the emergency department dueto a lack of patient flow within the hospital and in thewider community. Patients queued into the departmentfrom the ambulance entrance, stretching to the otherend of the department. A second queue formed in thearea known as majors one. In the afternoon a thirdqueue was in place in the corridor between theemergency department and the X-ray department. Manypatients in the queue had relatives with them, some ofwhom had to stand as there were insufficient chairsavailable. One of the patients queuing was a very elderlypatient who was terminally ill. When we left thedepartment at approximately 5pm they had been in thedepartment for over 13 hours. From the time we arrivedat 11am, until we left at 5pm, they were in the corridor.

• Doctors and nurses took medical histories from patientsin the corridor in earshot of other patients, relatives andpassers-by. They were afforded no privacy. Two relativesapproached us to tell us their family members needed abed pan. A third patient also asked us for our help. Onetold us they had asked a nurse three times for assistanceand told us “there’s going to be a puddle on the floor in

a minute.” Another told us they could not find a nurse.We could not find a nurse either so we informed thenurse coordinator. They expressed their frustration thatthey did not have enough staff to provide for these basicneeds. After a wait of wait of 10 to 15 minutes, patientswere taken in turn into a side room and givenassistance.

• As the department became more congested, there wasa shortage of trollies. We heard the coordinator ask theporter to find some more trollies. They were soinundated with requests that they did not have time tolook. We saw the ED information manager assistingnursing staff to clean trollies so they could be put backinto circulation.

• The children’s department was cramped and the waitingroom was frequently crowded, with relatives having tostand. This was also the case at times in the sub-waitingarea.

• There was a separate room which could be used toundertake mental health assessments. This did notcomply with safety standards for liaison psychiatryservices, developed by the psychiatric liaisonaccreditation network (PLAN). The room was also starkand unwelcoming. During our unannounced visit wefound the room littered with discarded items, includinga vomit bowl, cups and bottles. Staff told us the roomwas frequently used as an overflow assessment roomfor children and patients in minors so was not alwaysavailable for patients with mental health problemswhen needed.

• The trust was working collaboratively with the local A&Edelivery board and engaging with health and social carepartners to ensure there was a system-wide approach tomanaging demand and the impact that fluctuating andincreasing demand had on the ED.

• All health and social care partners, includingGloucestershire Hospitals NHS Foundation Trust,Gloucester Care Services NHS Trust, South WesternAmbulance Service NHS Foundation Trust, the counciland the Clinical Commissioning Group participated in adaily teleconference call to monitor patient flow andpressures and agree necessary action and escalationplans for the day ahead. At times of pressure, meetingstook place several times a day.

Meeting people’s individual needs




• The service took account of the individual needs ofpatients but was not always able to provide aresponsive service to patients with mental health needs.

• The department was accessible for people with limitedmobility and people who used a wheelchair. There werewheelchairs available in the department and staff couldaccess wheelchairs and trollies which couldaccommodate bariatric patients.

• The reception desk was too high for people of shortstature to see the reception staff. We saw several peoplestanding on tip toes at the desk. There was a lowersection provided for people in wheelchairs. Staff told usthe height of the desk was such in order to keep themsecure, but we felt it had the effect of creating a barrierbetween them and the patients.

• The department had not taken any steps to ensurepatient confidentiality at the reception desk. This was aproblem particularly for the clinical navigator who sat ata temporary desk in front of the main reception desk. Inthis small waiting area we able to overhear privateconversations.

• There was no hearing loop provided for people whowere hard of hearing and used a hearing aid.

• Reception staff had some translation aids available forpeople whose first language was not English. Staff toldus a telephone interpreter service could be provided.

• There were vending machines in the waiting area wherepatients and visitors could access food and drink. Therewas a muted television in the main waiting area, andsome reading material had been provided.

• There were male and female toilets and nappy changingfacilities were available in the children’s area. There wasa designated area for breast feeding mothers.

• There was a small separate waiting area for children,which was not overlooked by the adults’ waiting area. Itwas suitably furnished, decorated and equipped withtoys and a television. It was not appropriately equippedfor teenagers and this was commented on to us by ateenager during our inspection.

• We witnessed discussion at a medical staff handovermeeting about patients with particular identified needsand how these patients would be supported. Thisincluded a visually impaired patient, a patient with alearning disability and a patient whose first languagewas not English.

• There was a mental health liaison team whichsupported the ED and the Acute Care Unit from 8am to10pm seven days a week. The team, who were

employed by the local mental health trust, aimed torespond verbally to all crisis and urgent referrals formental health advice or assessment and provideassessment within two hours. Between June andOctober 2016 the service received 120 urgent referrals,of which 55% were seen within two hours. Mostnon-urgent referrals were seen within 24 hours. Outsideof these hours staff could contact the crisis hometreatment service provided by the mental health trust,or the on-call psychiatrist. Staff told us this service wasnot responsive as there were limited resources andpriority was given to people in the community, asopposed to patients who were regarded as being in a'place of safety’.

• The trust had a policy that patients with mental healthillness would not be admitted to an inpatient bedovernight, awaiting psychiatric assessment unless theyhad a physical illness or injury. Concerns had beenraised about this policy by an ED consultant at the EDgovernance meeting in November 2016. It was reportedthat there had been a number of incidents where highrisk patients had absconded from the ED because thedepartment did not have the appropriate staffing tosupervise these patients. The ED management teamtold us the mental health liaison team provision was tobe extended to cover the full 24-hour period fromFebruary 2017.

• There was a mental health liaison team to supportchildren under 16. This service operated from 8am to8pm Monday to Friday and from 9am to 5pm atweekends. The ED risk register highlighted “The risk ofproviding care to an increasing number of adolescentspresenting with self-harming behaviour who require aplace of safety but do not require medical care.” It wenton to say: “There is significant risk of these patientsfurther harming themselves or other patients, staff andvisitors as the resources are unavailable - to monitorand manage these patients in an acute trust is limited,as there is not the specialist facilities and clinicalexpertise….There is also a risk of a delay in the effectivetreatment of their mental health condition.” The EDconsultant with lead responsibility for mental healthtold us that children and young people who presentedin ED in mental health crisis were often admitted tohospital inappropriately because of delayed access tospecialist assessment and support.

• In April 2015 the local mental health trust appointed ahigh intensity case worker to identify strategies to more




effectively manage people with mental health issueswho frequently attended the emergency departments inGloucestershire. One of the objectives was to producemulti-agency management plans to support frequentattenders. Data produced in June 2016 showed anoverall reduction in both attendances and admissionswhere high intensity users were proactivelycase-managed. The patient records system identifiedpatients with management plans in place (by use of anicon) so that staff could refer to their history and seekguidance on how to best manage each presentation. Wewere told patients were able to provide input into theseplans; however, when we reviewed a sample of theseplans there was no evidence of any patient input.

• There was a specialist alcohol liaison service whichsupported the ED Monday to Friday from 9am to 5pm.Patients attending ED who were identified as havingharmful and dependent drinking behaviours wereoffered assessment, brief intervention and signpostingto relevant services. ED staff assessed patients and,where appropriate, provided them with a leaflet and anappointment to see the alcohol liaison worker at thenext available clinic slot or within 48 hours. Peopleattending ED on Friday or Saturday would be given anappointment for the following Monday. It was noted in areport to the psychiatric lesion meeting in November2016 that lack of service provision at weekend created areferral backlog and compensatory pressures onworkflow during the early part of the week.

• There was guidance available for ED staff to assist themto identify and manage patients with a learningdisability. There was a team of learning disability liaisonnurses who could be called upon to support staff. Staffreceived awareness training as part of their induction.This included meeting the trust’s learning difficultiesteam, understanding what their role was, how tocontact them, and what they can offer patients. Supportincluded the production of individual support plans forpatients with a learning disability. These were producedin an easy-read format and included patients’ likes anddislikes and preferences for care.

• Staff received dementia awareness training as part oftheir induction. They used purple butterfly stickers onpatients’ records and purple wrist bands to identifypatients with cognitive impairment. The departmentprovided ‘twiddlemitts’ for patients who were restless oranxious. Twiddlemitts are knitted mittens with items ofvarying texture attached inside and out. They are

knitted by volunteers using bright coloured wool andlots of attachments. They provide simple stimulation forpeople with dementia and other memory conditions.They minimise agitation, increase flexibility of thefingers and soothe fidgety hands.

• During our unannounced inspection we saw an elderlypatient being cared for on the corridor. They wereclearly confused and disorientated; they told us they didnot know why they were in the department. They werenot wearing a purple wristband and there was noindication on their notes to indicate they may needextra support. Staff acknowledged that the corridor wasnot an appropriate place for this patient. Since theinspection, the trust have acknowledged patients wereat high risk of a poor experience, at times ofovercrowding. As a result actions were being put inplace such as privacy screens for the corridors.

• The department had appointed a dementia championwho was a source of advice and support.

• The emergency department had recently developed ateam known as the Gloucestershire elderly emergencycare (GEEC), championed by an ED consultant. The aimwas to raise awareness of the issues faced by frail elderlypatients in the emergency department and to identifyareas where the experience of this patient group couldbe improved. The consultant had recently recruited anurse and a porter as GEEC champions and at the timeof our inspection was in the process of publicising theaims of the group. They planned to hold a ‘tea party’ inthe staff room the week following our inspection toencourage staff to join the group.

• Staff recognised the importance of supporting bereavedrelatives. Deceased patients were moved to a side roomwhere family members could spend time with them.

Access and flow

• People did not always receive care and treatment in atimely way. The trust was consistently failing to meet keynational performance standards for emergencydepartments:

• The trust was consistently failing to meet the standardwhich requires that 95% of patients are discharged,admitted or transferred within four hours of arrival atA&E. The trust did not meet the standard betweenJanuary and December 2016 and was worse than theEngland average, which was also below the standard.




However, the trust’s performance had shownimprovement over time. Performance for the emergencydepartment at GRH during this period ranged from69.7% in February (worst) to 86% in July 2016 (best).

• The trust also failed to meet the standardrecommended by the Royal College of EmergencyMedicine (RCEM) in relation to the time from arrival totreatment (one hour) in 10 out of 12 months in theperiod December 2015 to November 2016. In November2016 the median time to treatment was 60 minutes,compared with a national average of 59 minutes. At GRHthe median wait was higher, ranging from 85 minutes inOctober 2016 (best) to 106 minutes in February 2016(worst).

• Another important indicator for patients who requireadmission to a hospital ward is the time it takes for theirtransfer to take place from the time of the decision toadmit. Between January and December 2016, the trust’smonthly percentage of patients waiting between fourand 12 hours from the decision to admit until beingadmitted for this trust was generally better than theEngland average. The trust’s performance had improvedover time and in December 2016 trust performance was12%, compared to an England average of 17%. Over thesame reporting period, four patients waited more than12 hours from the decision to admit until beingadmitted.

• The department consistently achieved the nationaltarget which requires the number of patients who leavethe department before being seen by a clinicaldecision-maker to be less than 5%. This target isrecognised by the Department of Health as being anindicator that patients are dissatisfied with the length oftime they have to wait. Between December 2015 andOctober 2016 the trust’s monthly median percentage ofpatients leaving the trust’s urgent and emergency careservices before being seen for treatment was better thanthe England average. The trust’s performance wasconsistently between 1.2% and 2.3%. In November 2016,the trust’s performance was 1.6%, compared to theEngland average of 3%.

• The emergency department operated a clinical model(known as UTOPIA), whereby all emergency admissions,including those patients referred by their GP, attendedthe ED. The principal driver for this was to ensure theearliest possible review of all patients by a seniordecision maker who was capable of assessment and

instigation of initial management plans. It also enabledsome patients, who would otherwise have beenadmitted, to be assessed and discharged. There wasrecognition that the increasing numbers and acuity ofpatients, and poor patient flow within the hospitalleading to crowding and associated risks, made thismodel unsustainable, given the current resourcing andcapacity of the emergency department. We were showna report which showed that on one day in the lastmonth, 56 patients were referred by their GPs forassessment or admission. All of these patientspresented at the emergency department and wereassessed by ED staff, rather than specialist teams.Detailed diagnostic work was underway both within theemergency department and within the wider system todevelop a model which was affordable and sustainable.

• There was detailed monitoring of breacheshour-by-hour in the emergency department and by thesite management team. There was a weekly breachmeeting chaired by the chief operating officer andmonthly performance was reported to the emergencycare board against a monthly trajectory agreed withNHS Improvement (NHSI). It was reported in theemergency pathway report that the NHSI recoverytrajectory was met in quarter two (July to September)but performance in October and November were belowtrajectory. The report highlighted the multiplechallenges in maintaining progress:

• The trust’s emergency departments had seen a 4.9%increase in attendances in the 12 months to November2016

• There was a significant shortage of junior and middlegrade medical staff in the emergency department

• High bed occupancy levels, average length of stay,medically fit for discharge patients and delayedtransfers of care. The report stated “Occupancy levels atGloucestershire Hospitals have historically run at morethan 95% for many years. The Trust considers thisunacceptable and recognises the impact on thepotential quality of care and the impact on staff. TheTrust recognises a significant piece of work is required tosustainably reduce occupancy rates to acceptable levelsof 92.5% and elements towards achieving a reducedoccupancy sit across a number of work streams withinthe programme…”




• The trust’s risk register recorded “Delayed discharge ofpatients who are on the medically fit list above theagreed 40 limit leading to detrimental effects oncapacity and flow of patients through the hospital fromED to ward.”

• Analysis of the main contributing factors to four hourbreaches in November 2016 showed that bedavailability was by far the biggest single cause ofbreaches (35.9%). The second biggest cause was‘awaiting assessment’ (20.57%) and the third biggestcause was ‘others’ (this included waiting for diagnostics,porters, transport and specialists).

• The trust recognised that crowding in the ED presenteda risk to patient safety, patient experience andperformance against key waiting time targets. There wasa trust Patient Flow and Escalation Policy (September2016) which set out steps to mitigate these risks byensuring that patient flow throughout the two hospitalswas managed.

• There were regular capacity and flow meetingsthroughout the day and these were attended by arepresentative from the ED. The site management teammaintained an organisational overview of capacity andissues affecting flow, and liaised closely with the EDcoordinator.

• The escalation policy described and rated theescalation of each hospital, ranging from green (low risk)to black (very high risk). The escalation level wastriggered by bed capacity or ED capacity (numbers andbreaches) and was reviewed regularly. In the ED,escalation status was reviewed by the nurse coordinatorand consultant at the hourly board round. Theescalation status of the department was calculatedusing a score system which took into account incomingambulances, total arrivals, majors’ cubicles in use,resuscitation cubicles in use and total patients indepartment.

• Escalation status was communicated to, and reviewedby, the site manager and the designated trust dutymanager. When the ED was at red or black status, thecoordinator implemented the ED escalation policy.

• There was a series of action plans in place for eachescalation status. Actions included opening additionalbeds, providing additional staff, cancelling training anddiverting patients to other hospital sites. Whenescalation status was declared black, a major incidentwould be declared.

• The trust had developed a number of initiatives toprevent unnecessary ED attendance and/or admissionto hospital and thereby improve patient flow.

• From September 2014 all GP calls for an ambulancewere handled by the Gloucestershire Single Point ofAccess run by a local care trust, where alternatives to EDattendance would be considered first. However, thespecialty director told us some GPs opted out of usingthis system.

• The trust’s website provided advice to members of thepublic to encourage them to choose the mostappropriate service when they needed urgenthealthcare advice or treatment. The Advice ASAPcampaign included a short video and a smart phoneapplication which allowed people to search by serviceor by symptoms. There were links to a range of localservices, including primary care (including out of hours),NHS 111, pharmacies and local minor injury and illnessunits. Live information was also posted on the websiteshowing how busy each ED was and the average timepatients would have to wait to be seen.

• The Older People’s Assessment and Liaison (OPAL) teamvisited the emergency department each week day andproactively identified patients over the age of 80 forwhom admission may be avoided if a suitable carepackage was put in place. The team consisted of aconsultant in care of the elderly, supported by a registrarand a nurse.

• The OPAL team liaised closely with the integrateddischarge team provided by a local care trust to work inthe ED and on the Acute Care Unit. The team, made upof health and social care professionals, assessedappropriate patients and, where possible, directed themto other services in the community. It also supportedpatients (inpatients and ED patients) who neededongoing health or social care services after they weredischarged and helped to facilitate their early discharge.The service operated from 8am to 8pm Monday toFriday and from 9am to 5pm at weekends and over bankholidays.

• The trust was piloting a primary care service based inED. The trial was a joint initiative with the localambulance service and employed a GP in thedepartment. A clinical navigator was based in thewaiting room and directed appropriate patients (thosewith a minor illness) to see a GP or an advanced nursepractitioner.




Learning from complaints and concerns

• Between November 2015 and October 2016 there were103 complaints about urgent and emergency care atGRH. Twenty- seven complaints (26%) were categorisedas ‘patient care’.

• The trust took an average of 38 working days toinvestigate and close complaints. This was slightlylonger than stipulated in the trust’s complaints policy,which stated complaints should be responded to in 35working days.

• Staff we spoke with were with were familiar with thecomplaints procedure. They told us they would try toarrange for complainants to speak with a seniormember of staff or direct them to the Patient Advice andLiaison Service (PALS). There were complaints leaflets inthe department which advised people how to complain,and these were also available via the trust’s website.

• Complaints were discussed at governance meetings. Aconsultant was the designated lead for complaintswithin the department and was responsible foridentifying themes and disseminating learning.Communication methods included ‘Message of theweek’ where short catchy reminders were displayedaround the department.

• The trust had introduced a new digital methodology forthe friends and family test in July 2016 and 0this hadresulted in a big increase in the response rate forSeptember 2016 (26% trust-wide).

Are urgent and emergency serviceswell-led?

Good –––

We have rated this service as good because:

• There was a strong, cohesive and well-informedleadership team who were highly visible and respected.

• There was a detailed improvement plan in place withclear milestones and accountability for actions.

• The emergency department produced high qualityinformation which analysed demand capacity andpatient flow, and was used to inform the improvementplan.

• There were robust governance arrangements in place.Clinical audit was well-managed and used to driveservice improvement. Risks were understood, regularlydiscussed and actions taken to mitigate them.

• There were cooperative and supportive relationshipsamong staff. We observed exceptional teamwork,particularly when the department was under pressure.

• Staff felt respected, valued and supported. Morale wasmostly positive, although to an extent was underminedby workload pressures.

• Service improvement was everybody’s responsibility.Staff were encouraged and supported to undertakeservice improvement projects.

However:

• Safety concerns which we identified at our lastinspection had not been addressed, despite theintroduction of new processes. Poor patient flowremained the major barrier to progress. The emergencydepartment’s management team did not feel there wasa culture of collective responsibility within the trust inrelation to patient flow. There was frustration expressedthat the emergency department bore adisproportionate level of risk, while the responsibility forthe exit block sat with others. The emergencydepartment was unable to influence the cultural shiftwhich was required to address this significant barrier toimproving patient flow and capacity.

• Pressures faced by staff in the emergency department inrelation to crowding were well understood andarticulated by the management team but it did notappear that the risks relating to staff wellbeing,resilience and sustainability, had been widely shared orescalated within the organisation and they were notincluded on the department’s risk register.

• There was a limited approach to obtaining the views ofpeople who used the service.

• Workload pressures prevented opportunities for staffreflection or meaningful staff engagement andinvolvement in shaping the service.

Vision and strategy for this service

• The vision for the service was for the provision of allstrands of unscheduled care to be provided under oneroof, 24 hours a day, seven days a week. This includedthe expansion of primary care services, mental healthliaison and support, ambulatory emergency care,further development of the frail elderly care pathway




(including short stay beds), and the provision of largerand updated premises to accommodate these services.It was anticipated this would take several years toachieve.

• There was a trust-wide five year strategic plan and anoperational plan for 2016/17. Priority areas wereidentified in the operational plan as:

• addressing the inability of the local health and socialcare system to manage demand within current capacity,

• matching workforce with clinical needs,• developing the physical estate.

• The emergency care pathway was identified as a trustpriority for improvement and plans were set out in theemergency care programme. A series of external reviewshad taken place to examine the issues affectingoperational effectiveness and patient flow. Mostrecently an improvement director appointed by NHSImprovement had undertaken diagnostic work whichhad resulted in the development of an emergency careprogramme. Recommendations had been incorporatedinto the trust’s Emergency Care Board (ECB) plan andprogress against milestones was closely monitored bothby the ECB and the trust board.

• A work programme was developed under the umbrellaof an economy-wide plan monitored by the A&E DeliveryBoard. Six work streams with defined objectives weredeveloped and progress against each of the workstreams was monitored by the emergency care board.Work streams were:

- Emergency Department,

- Site management,

- Safer patient flow bundle,

- Clinical patient flow model,

- Bed distribution,

- Remove delays to discharge.

• Within the emergency department work stream theobjectives were:

• To review staffing and skill mix• To review four hour breaches• To increase ED capacity

Governance, risk management and qualitymeasurement

• There was an effective governance framework.Information was regularly monitored to provide aholistic understanding of performance, including safety,quality and patient experience.

• There was a bi-monthly clinical governance meetingattended by senior nursing and medical staff. A standardagenda included incidents and risk management,patient experience, complaints, safety alerts, clinicalguidelines and audit. Key messages werecommunicated by distribution of minutes, email,bulletins, teaching sessions and handovers. Theemergency department clinical governance meetingreported to the divisional quality meeting, whichreported ultimately to the board. Divisional qualityreports monitored and reported on key safety andquality standards. There were also monthly operationalmeetings where items discussed included staffing andperformance.

• One of the ED consultants took the lead overall forquality and governance. All ED consultants haddesignated specialist lead roles, such as clinical audit,complaints, mental health, paediatrics, elderly care, andmissed radiological pathology.

• There was a monthly emergency pathway performancereport to the board, detailing progress against theemergency care programme board milestone plan.Performance metrics included safety, patientexperience, incidents, complaints, morbidity andmortality. There were a number of county-wide projectsto streamline the urgent care system as detailed in asystem-wide plan. This involved working with healthand social care partners.

• The emergency department maintained a risk registerwhich was regularly monitored and reviewed atdepartmental and divisional levels. Risks aligned withthe areas of concern identified to us by managers andstaff, with the highest risk being associated withdemand, capacity and patient flow. However, risks inrelation to staff wellbeing and resilience, whilstunderstood and articulated to us, were not identified inthe risk register.

• There were good relationships with third partyproviders. For example, the director of nursing metregularly with their counterpart in the local mentalhealth trust and there were regular meetings with EDand the mental health liaison service.

• There was a systematic programme of clinical auditwhich was used to monitor quality and safety. At our




previous inspection we raised concerns that the auditprogramme was not well-managed, actions arising fromaudits were not completed in a timely manner and wecould not be assured that learning and improvementsconsistently took place. On this inspection we found thiswas much improved. Responsibility for managing theaudit programme had been passed to anotherconsultant, who had reviewed all audits going back to2012/13, ensuring that all actions were completed. Thelead consultant had a good overview of all ongoingaudit, action plans and plans for re-audit. We reviewed anumber of audits and saw action plans had beencompleted, discussed at mortality and morbiditymeetings and learning points disseminated.

Leadership of service

• There was a local management triumvirate comprisingof a specialty director, matron and general manager.They were supported by an operations informationmanager. They were a well-informed, cohesive teamwho were highly respected by staff. They demonstratedpassion and drive to meet the significant challenges inunscheduled care and to develop and improve theirservice.

• Staff told us the local management team was visible,approachable and supportive. During our visit they wereall highly visible in the department and providedassistance when there were capacity issues. Thetriumvirate team felt well supported by the divisionalmanagement team and the new chief executive wasdescribed as “a breath of fresh air”. However, there wasfrustration expressed that the emergency departmentbore the risks associated with lack of patient flow, whileresponsibility for managing the exit block sat withothers and progress in addressing this was slow.

Culture within the service

• Staff in ED told us they felt respected, supported andvalued by their immediate managers and their peers.Staff morale was mainly positive, with many staff citingteamwork as one of the best things about working in theemergency department. We observed exceptionalteamwork during our visits, with all disciplines andgrades of staff working together seamlessly and helpingeach other out when needed. We saw doctors takingblood when nurses were busy, and managers werefrequently seen in the department helping out in anyway they could to ease the pressure on clinical staff.

• Morale was inevitably undermined by workloadpressure and managers expressed concerns about theimpact that workload was having on the physical andmental wellbeing of staff. This was most acutely felt bynursing staff but there were also concerns about thefrequency with which consultants were workingadditional hours to support the department, particularlyat night. A workplace stress risk assessment undertakenin May 2016 had identified some concerning messages.It was reported that increasing ED attendances andpatient acuity, combined with delays in diagnostic andspecialty review, and reduced bed capacity, had led toan excessive increase in staff workload without anyadditional staff to deal with it. It was noted this had “aprofound impact on the stress and wellbeing of staff.”This was highlighted by :

• High staff turnover• Concerns about workload and the working environment• Concerns about a lack of communication within the

department (difficulty releasing staff to attend staffmeetings and in house teaching activities).

• Staff feeling disconnected with changes at work.

• Positive feedback was received in relation to:

• The skills and abilities of staff being matched to thedemands of the job and the provision of training

• Staff said they were encouraged to use their skills andinitiative

• Staff felt supported by their colleagues• Staff had adequate feedback and resources to enable

them to carry out their role.

• An action plan was in place to address areas of concern.

Public engagement

• The ED used the friends and family test to capturepatient feedback and this was discussed at governancemeetings.

• The service provided us with no further examples ofpublic engagement.

Staff engagement

• There were limited opportunities for face to face staffengagement, although staff were kept informed viaemail bulletins, newsletters and handover meetings.There were departmental meetings held for nursingstaff. However, these took place infrequently and werepoorly attended due to operational pressures.




• Nursing staff had not been actively engaged so that theirviews were reflected in the planning and delivery ofservices and in shaping the culture. None of the ED staffwe spoke with could articulate the department’s visionor strategy.

• Staff told us they were encouraged to raise concernsand they felt they were listened to.

Innovation, improvement and sustainability

• There was strong sense of drive to improve the service.There was an emergency department improvementplan which had been developed in response to anumber of drivers, including our previous inspectionreport, recommendations from Monitor (now NHSImprovement), commissioning targets and auditfindings.

• The trust was linking with other centres whereinnovative approaches to junior doctor roles haveattracted candidates and were also reviewingnon-medical practitioner models as a means ofaddressing medical staffing vacancies.

• There was a Quality Improvement Academy establishedin the trust in June 2015. Staff were supported toundertake projects which were identified as areas whichcould make improvements to quality and safety.Projects in the emergency department included BiersBlock with collies fractures, early management of chestpain and ECGs, early management of asthma,improvement of pain management in emergencydepartments.





Effective Requires improvement –––



Well-led Requires improvement –––

Overall Requires improvement –––

Information about the serviceGloucester Hospital Foundation NHS Trust providesinpatient medical services at Gloucestershire RoyalHospital and at Cheltenham General Hospital. Services atCheltenham General Hospital are reported in a separatereport. However, both locations are overseen by onemanagement team (the medical division) and as such,are regarded as one service within the trust with somestaff rotating between the two locations. For this reason,some duplication in the two reports is inevitable.

The Medical care service at the trust provides care andtreatment for nine specialties. There are 548 Medicalinpatient beds located across 22 wards. In August 2016,there were 358.42 nursing whole time equivalents (WTE)and 274.79 other clinical WTE for the medical services.

A site breakdown can be found below:

• Cheltenham General Hospital: 200 beds are locatedwithin nine wards

• Gloucestershire Royal Hospital: 354 beds are locatedwithin 13 wards

The trust had 72,120 medical admissions between April2015 and March 2016. Emergency admissions accountedfor 30,633 (42%), 1,671 (2%) were elective and theremaining 39,816 (55%) were day case.

Admissions for the top three medical specialties were:

• General Medicine 28,108

• Medical Oncology 19,813

• Gastroenterology 10,486

Gloucestershire Royal Hospital (GRH) has 11 medicalwards, an acute medical assessment unit and anambulatory care unit. At the time of our inspection, twoadditional wards were in use for medical patients to copewith increased demand due to winter pressures.

We inspected the medical services between 24 and 27January 2017 and also visited the service unannouncedon 6 February 2017. During the inspection, we visited theinpatient wards: Gallery Wing 1 (General medicine), Ward4A (general old age medicine and endocrine), 4B (Elderlycare), 6A/B (stroke care), 7A (dermatology), 7B (renalcare), 8B (respiratory care), 9B (general old age medicine)and the cardiology wards 1, 2 and the cardiac care unit.We also visited the acute assessment unit (ACUA),medical day care unit, the ambulatory care unit,discharge lounge and the endoscopy unit.

We spoke with 71 members of staff including nurses,doctors, allied health professional such as pharmacist,physiotherapist, occupational therapists, ward clerks,housekeeping staff and volunteers. We spoke with 20patients, three relatives and we reviewed 17 sets ofmedical notes. We observed interactions between staffand patients, attended bed meetings andmultidisciplinary meetings, observed part of ward roundsand looked at the environment in the different wardareas.

Medicalcare

Medical care (including older people’s care)


Prior to, during and after the inspection we looked atinformation requested and sent to us by the organisation,which included audit results, minutes of meetings,organisational policies, incidents, complaints andpositive feedback.


The team included CQC inspectors and a variety ofspecialists including a retired consultant cardiologist, award manager and a nurse.

Summary of findingsWe rated this service as requires improvement because:

• Nursing staffing levels were below establishment andwards relied on bank and agency to cover shifts everyday.

• The service did not assess or record the acuity ofpatients on each shift and on each ward to ensuresafe staffing levels.

• The medical service did not consistently review theeffectiveness of care and treatment through nationalaudits.

• The service had a strategy to understand andimprove performance on hospital-based mortalityindicators. While most specialities held mortality andmorbidity (M&M) meetings monthly or quarterly wewere concerned that not all specialties heldmeetings regularly and how effectively learning wasshared.

• There were some concerns about the safe transfer ofpatients receiving intravous therapy duringambulance transfers to other hospitals.

• Staff did not always follow infection controlprocedures when entering wards and ensuring thecleanliness of equipment such as commodes.

• Staff did not always comply with legislation regardingthe Control of Substances Hazardous to Health(COSHH).

• Daily checking of equipment such as resuscitationequipment was not carried out in line with the trust’spolicy in all areas.

• Staff did not monitor fridge temperaturesconsistently or take actions where these fell out ofnormal range, which meant medicines were notalways stored correctly.

• Staff were unsure of when to dispose of somemedicines in line with manufacturer’srecommendations.

• Records were not stored safely to ensure patient’sconfidentiality was maintained.

• Staff did not always assess risks to patients or followup identified risks with mitigating care interventions.

• The medical service did not consistently review theeffectiveness of care and treatment through nationalaudits.

Medicalcare



• Staff did not always put actions in place whenpatients were at risk of malnutrition.

• Compliance with annual appraisals were below thetrust’s target.

• There were delays in discharging patients; althoughthis was largely caused by factors outside of themedical services remit.

• Information was not always accessible to staffincluding information about care and treatmentpathways.

• The delivery of cardiology services did not meet theneeds of the local population.

• There were delays to discharges, which meantpatient flow through the hospital was compromised.

• The environment did not meet the needs of patientswith dementia.

• The service was not always compliant with theaccessible information standards and informationleaflets were not readily available for patients forwhom English was not their first language.

• Risks registered on the risk register were not alwaysaligned with risks in the service

• There was a limited approach to obtaining the viewsof patients and their relatives

However:

• Staff understood their responsibility to reportincidents and there were processes in place to reviewincidents and ensure learning was shared across thetrust.

• The endoscopy unit had safe processes in place toensure staff decontaminated and sterilisedequipment in line with best practice.

• Staff were aware of their responsibilities foridentifying and reporting safeguarding issues.

• There were safe processes in place to review patientsand ensure care and treatment plans were followedup.

• Patients were positive about the way they weretreated and cared for in the medical wards. Wherestaff were observed treating patients with kindness,dignity, respect and compassion.

• Patients praised staff for providing furtherinformation when asked.

• There was a competence training and assessmentframework in place to ensure nurses were competentto carry out extended skills and nursing staff weresupported with revalidation processes.

• There was an effective framework for ‘board round’and ward rounds and included input from staff fromthe multidisciplinary healthcare team.

• Processes were in place to ensure consultantsreviewed patients seven days a week.

• Staff were aware of the mental capacity assessmentand applications for deprivation of libertysafeguards.

• The trust’s referral to treatment time (RTT) foradmitted pathways for medical services was betterthan the England overall performance betweenNovember 2015 and October 2016.

• The trust had a clear vision and some specialitieswithin the medical division had a vision to expandand improve services.

• Staff felt supported by managers and seniormanagement felt assured by the new executive team.

Medicalcare



Are medical care services safe?


By safe, we mean people are protected from abuse andavoidable harm. We rated safe as requires improvementbecause:

• Nursing staffing levels were below establishment andwards relied on bank and agency to cover shifts everyday.

• The service did not assess or record the acuity ofpatients on each shift and on each ward to ensure safestaffing levels.

• Staff did not always follow infection control procedureswhen entering wards and ensuring the cleanliness ofequipment such as commodes.

• The wards did not display evidence of when areas suchas toilets were last cleaned and we did not seeenvironmental audit result displayed on the wards wevisited.

• Staff did not always comply with legislation regardingthe Control of Substances Hazardous to Health(COSHH).

• The fabric of the building did not always ensure efficientcleaning could be carried out.

• Daily checking of equipment such as resuscitationequipment was not carried out in line with the trust’spolicy in all areas.

• Fridge temperatures were not monitored or actionstaken where these fell out of normal range, which meantmedicines were not always stored correctly. Staff wereunsure of when to dispose of some medicines in linewith manufacturer’s recommendations.

• Records were not stored safely to ensure patientconfidentiality was maintained.

• Staff did not always assess risks to patients andfollowed up with mitigating care interventions.

However:

• Staff understood their responsibility to report incidentsand there was evidence of learning from incidentsacross the organisation.

• The endoscopy unit had safe processes in place toensure staff decontaminated and sterilised equipmentin line with best practice.

• Staff were aware of their responsibilities for identifyingand reporting safeguarding issues.

• There were safe processes to review patients and ensurecare and treatment plans were reviewed.

Incidents

• There had been no never events reported in the medicalservices in the period from December 2015 to November2016. Never events are serious patient safety incidentsthat should not happen if healthcare providers follownational guidance on how to prevent them. Each neverevent type has the potential to cause serious patientharm or death but neither need have happened for anincident to be a never event. However, there had been anever event (misplaced nasogastric feeding tube (NG))in another service within the hospital. As a result,learning had been shared with other services/departments in the trust. We asked staff on ward 6Babout checking the correct placement of NG tubes priorto commencing feeding as we noted five patients withNG feeding in progress. Staff demonstrated robustknowledge of safe practices following the never event inthe hospital. Changes had been introduced and nowtwo members of staff were required to check for thecorrect position before NG feeding commenced. Staffalso described the process for escalation if this couldnot be confirmed. We noted this was all documented inthe medical notes.

• In accordance with the Serious Incident Framework2015, the trust reported seven serious incidents (SIs) inmedical care, which met the reporting criteria set byNHS England from December 2015 to November 2016.Of these, the most common type of incidents reportedwas slips/trips/falls and healthcare associated/acquiredinfection control incident, both with two reportedincidents.

• There was a good incident reporting culture and staffwere actively encouraged to complete electronicincident reports. Staff were aware of their responsibilityto report incidents. We saw evidence that lessons werelearnt and improvements were made when things wentwrong.

• The clinical risk lead reviewed reported incidents fromthe medical services. Any potential serious incidentswere discussed with the ward staff and additionalinformation gathered. Serious incidents were reviewedat a scoping meeting and an investigator allocated tocarry out an investigation of the circumstances and

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outcomes. Incidents that were not considered to beserious incidents were investigated appropriately andactions identified and taken. Feedback was provided tothe original reporter of the incident.

• Trends and patterns of incidents were analysed by theclinical risk team and reported to the medicinedivisional leads. The top five incidents reported withinthe medicine division were falls, pressure damage,violence and aggression, medicine errors and staffing.

• Staff reported incidents using an electronic incidentreporting system. Staff understood their responsibilityto report incidents and found the system easy to use.We asked staff about changes in practice attributed tolessons learnt from reported incidents and many staffgave us examples. For examples, staff on the respiratoryward told us how they had changed the method fordelivering non-invasive ventilator support, as they hadfound the previously used masks to cause pressuredamage to the ears. They now used a facemask and hadnot had one incident of pressure damage since. Theward sister on ward 8B told us how learning from aserious incident had resulted in an extra registerednurse at night and tracheostomy training was updatedevery three months to ensure staff kept their skillsupdated.

• Nurses told us about changes to supporting patientswith nasogastric (NG) tubes to ensure correct positionbefore NG feeding was commenced. There wasguidance on how to check the position of NG tubes,which was an assessed competence and the NG tubehad to be checked and confirmed by two nurses beforeNG feeding was commenced. If there were any concernsabout NG placement, they would refer to a doctor andthe patient may have an x-ray to confirm position. Otherchanges because of incidents included increasedfrequency of care rounds and the introduction of ‘fallsalarms’ for patients at high risk of falling.

• Staff on ward 7B described a change of practicefollowing a serious incidence when a patient developeda pulmonary embolism following line insertion inpreparation for dialysis. The ‘line room’ was previouslystaffed by a doctor and a healthcare assistant, but thiswas changed and the doctor was now supported by aregistered nurse.

Duty of Candour

• The duty of candour refers to Regulation 20 of theHealth and Social Care Act 2008 (Regulated Activities)

Regulations 2014. This Regulation requires the trust tobe open and transparent with a patient when things gowrong in relation to their care and the patient suffersharm or could suffer harm, which falls into definedthresholds. Staff were aware of the ‘duty of candour’legislation although not all staff had attended trainingor read the policy relating to it One ward sister statedthey had been too busy to look at the intranet to see ifthere was training or a policy but suspected thatinformation would be available.

• We looked at investigations into serious incidents. Therewas a section within the standard framework, whichdetailed support given to patients and carers. However,there was no specific evidence that the outcomes of theinvestigations were shared with patients and their carersas appropriate.

Safety thermometer

• The hospital reported data on patient harm to the NHSHealth and Social Care Information Centre each month.This was nationally collected data providing a snapshotof patient harms on one specific day each month. Thisincluded hospital-acquired (new) pressure ulcers(including only the two more serious categories of harm)and patient falls with harm.

• Ward staff in all areas told us they regularly undertookmonthly safety thermometer audits, which were sent tothe clinical audit department.

• Managers kept safety thermometer audits in files in themanager’s office and displayed the safety thermometerresults in most ward areas as ‘harm free care’.

• Staff collected data one day each month to monitorperformance in delivering harm free care. Data from thePatient Safety Thermometer showed that the trustreported 86 pressure ulcers, 39 falls with harm and 38catheter urinary tract infections between November2015 and November 2016.The data showed that theprevalence of pressure ulcers and falls were bothreducing over the period and there was a similar trendfor catheter urinary tract infections.

• There had been an increase in reporting of pressureulcers because staff were now required to report allpressure ulcers (grade 1-4) as an incident. Althoughthere was an increase in pressure ulcers reported, allgrade 2 pressure ulcers were now reviewed by a tissue

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viability specialist nurse and as a result, there had beena decrease in pressure ulcers deteriorating andsubsequently, fewer grade 3 and grade 4 pressureulcers.

• The trust used medical photography to help documentthe severity of the pressure ulcers when first noted,which helped staff to evaluate the effectiveness oftreatment and care. Each ward had a pressure ulcerdressing trolley with dressings suitable for each categoryof pressure ulcers from grade 1 to 4. The trolleys alsocontained the ‘European pressure ulcer advisory panel’(EUPAP) grading tool, the trust’s skin care protocol, careplan (SSKIN bundle), patient information leaflets,wound care assessment chart and different types ofdressings.


• There were not always reliable systems in place toprevent and protect patients from healthcare associatedinfections.

• We found some ward areas, including corridors, werecluttered and untidy with visibly dusty floors, and doorsleft open to both treatment rooms as well as sluicefacilities. Not all equipment had stickers to indicatewhen they were last cleaned (including commodes,although we could see that seats had been lifted). Wealso saw some clinical waste bins overflowing withaprons and gloves.

• Wards had fabric curtains to help provide privacy andmaintain dignity for patients. However, ward staff,including domestic staff and ward managers, did notknow when the curtains were last washed. We were toldby the staff, the domestic staff would always change thecurtains if a bed space, side room or ward bay was deepcleaned following the discharge of a patient with aninfectious disease. The supervisor in the linendepartment told us that they changed the curtains everythree months regularly, more often if visibly dirty, orfollowing the discharge of patient with an infectiousdisease. The linen department kept records of changesto ensure this happened regularly and to help plan thework load. An outside contractor collected the curtainsand laundered these off site. They told us this followedthe trust’s ‘curtain procedure policy and action plan’. Wechecked the Department of Health: Health Building note00-09: Infection control in the built environment’ andconcluded that practice was in line withrecommendations for curtains in clinical area.

• Staff wore clean uniforms and had their hair tied up ifapplicable, however, staff did not always follow policyon the use of hand gel when entering wards. On ward 6Bwe saw eight members of staff enter the ward withoutusing hand gel some of these staff did not also complywith the policy to be ‘bare below elbows’. On ward 7Bwe observed four members of staff enter the wardwithout using the hand gel.

• Staff on the wards decontaminated their hands in linewith NICE guidance (QS 61 statement three, 2014) whichstates that people should receive healthcare fromhealthcare workers who decontaminate their handsimmediately before and after every episode of directcontact or care. Staff were required to complete handhygiene audits monthly. However mangers did notalways display the results on the wards for patients andvisitors to see. Audit results demonstrated compliancewas between 91% and 100% for clinical staff in theperiod from April to October 2016, against a target of95%.

• Registered nurses on most wards used tabards whenadministering medication to help prevent interruptions.On some wards, these were fabric and only washedonce a week or more frequently if visibly dirty. On ward8B we observed staff wearing plastic tabards that couldbe disposed of after each use.

• The wards did not display evidence of when areas suchas toilets were last cleaned and we did not seeenvironmental audit result displayed on the wards wevisited. On the cardiac wards, we saw a toilet, which wasuntidy, with personal toiletries left, and a used bedpanliner on the floor. Wards did not display records of whendomestic staff had last cleaned the toilet facility

• There was not a consistent method of informing staffwhen commodes were clean prior to patient use onseveral wards. Staff told us that the sticky labels wereunreliable and they left the commode lid upside downto show it had been cleaned. Several wards hadlaminated notices, which they put on the cleancommodes.

• Staff did not always comply with legislation regardingthe Control of Substances Hazardous to Health(COSHH). On ward 9B we saw there were two containerswith chlorine tables in an unlocked cupboard. On theacute medical assessment unit (ACAU), we saw threecontainers of chlorine tablets and diluted chlorinesolution was accessible in the unlocked sluice. On ACAU,we saw nine small and one large sharps bins placed on

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a trolley in the ward area awaiting collection fordisposal. These were accessible to patients and visitorsto the ward and although closed appropriately therewas a risk of access to contaminated sharp equipmentsuch as needles.

• We observed practices for barrier nursing patients withpotential infectious diseases. Staff wore personalprotective equipment such as gloves, apron and masksas identified through risk assessment. We observed staffchallenging people if they entered the isolated areawithout personal protective equipment and ifsomebody (other than the patient) sat on the bed.

• In 2016, the majority of nursing staff had completedtheir training in infection prevention and control. Thetrust target of 90% was met and exceeded with 94.6% ofthe nursing staff having undertaken infection,prevention and control training. However, medical staffwere not meeting the trust target for infectionprevention and control training. The trust target of 90%was not met as 85.4% of medical staff had undertakenthe training.

• The endoscopy unit had facilities to maintain infectioncontrol procedures safely. The unit had adecontamination area, which was separate from cleanareas and had separate doors. There were fourautoclaves for sterilising the equipment and staff worepersonal protective equipment such as apron, glovesand a face shield. The unit had procedures in place toensure safe practice if patients were admitted withknown transmittable infections such as tuberculosiswhich included carrying out the procedure at the end ofthe day and follow this with a deep clean of the area.Staff had access to infection control policies such asguidance on infection control practice in patients withblood borne virus or Creutzfeldt-Jakob disease (CJD).The unit also had a separate isolation recovery room.

• The renal ward had processes in place to prevent andprotect patients from blood borne viruses. There wasspecific policies available to staff and processes in placeto prevent cross contamination from patient with knowninfections. The unit had processes in place for testingthe water quality weekly for Legionella. Anyabnormalities were reported as serious incidents and topublic health authorities as per national guidance.

• The trust reported one case of methicillin-resistantstaphylococcus aureus (MRSA) bacteraemia and 12cases of clostridium difficile (CDiff) multiple drugresistant organisms, between August 2016 and January

2017. The standard set was nil cases of MRSAbacteraemia. The standard for Cdiff infections (post 48hours as an inpatient) was 30 cases of Cdiff per year(running total). The trust monitored this and the numberof cases did not exceed this standard from January toOctober 2016.


• The design, maintenance and use of facilities did notalways keep people safe.

• Staff did not always check bed spaces to ensureemergency equipment was present following dischargeof a patient. On the cardiac ward, we checked an emptybed space, which was declared ready for admission ofanother patient. There was no oxygen tubing and nosuction chamber, which meant that both of these werenot ready for use in an emergency.

• On ward 7B the floor of the main corridor on the wardwas worn and looked dirty. Both wards 7A and 7B werecluttered with equipment stored in the corridor andgenerally shabby. The paint on the ceiling tiles in ward7B was chipped and dilapidated. Ward 7A had a roomdesignated as the dayroom; however it was not fit forpurpose. The blood fridge and a hoist were stored in it.The skirting board had come away from the wall and theflooring was worn; which meant that effective cleaningwould be difficult. There were no storage facilities onward 7B for cleaning products for domestic staff. Theward manager told us of a plan to re-locate thespecialists nurses based on the ward and their officechanged into storage space.

• However, ward 7B had a dedicated treatment room forthe placement of tunnelled lines under ultra soundguidance. We checked equipment and consumablesand found them to be in date. Staff locked the roomwhen not in use.

• The medical day unit comprised of two, six bedded bayswith ten chairs in each. A variety of short term and longterm medical conditions were treated in the unit, whichincluded pre-operative anaemia, liver conditions andinflammatory bowel conditions. There was a wide rangeof treatments carried out such as blood transfusions,iron infusions, infliximab infusions, and a deep veinthrombosis service. The service treated up to 35 patientsin a day. The bays were cramped and patients had verylittle space between chairs, several patients had visitorswith them and this made the bay even more cramped.This compromised patient’s dignity and confidentiality.

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• In cardiology the equipment used for trans oesophagealechocardiogram (a test that allows medical staff to takedetailed images of the heart using high pitched soundwaves), did not produce clear images. As a result, allsuch procedures for both in patients and outpatientswere being undertaken at Cheltenham General Hospitalwhist a replacement was being procured.

• Not all wards had their own resuscitation trolley. Forexample, the discharge lounge shared resuscitationequipment with the ambulatory care unit and themedical day case unit. Staff were clear about where toaccess it and also about responsibility for daily checkingof the trolley.

• However emergency equipment such as resuscitationtrolleys were not checked daily. We visited many wardareas and none of them had 100% compliance for dailychecking. For example, staff on cardiology ward two hadnot checked the resuscitation trolley on four daysbetween 1 and 25 January 2017 and the defibrillatorhad not been checked on six days in the same period.There was not always a checklist to audit daily checkingof defibrillators throughout the medical services. Forexample, ward 9B did not have a list to log dailychecking. When we raised this with a senior ward nurse,they appeared unaware that staff should log this daily.

• As some areas, such as bathrooms, did not have accessto piped oxygen or suction in the event of anemergency, portable equipment was located next to theresuscitation trolley. However, there was an inconsistentapproach to checking the safety and working order ofportable equipment. Staff did not always know whenthe equipment was last checked and there was noauditable list to provide this information.

• The trolleys contained medication and equipment usedin the event of a cardiac or respiratory arrest. Medicationwithin the trolleys was stored in tamper-evidentcontainers. However, none of the drawers within thetrolleys were themselves tamper-evident, so medicinescould be removed between checks without this beingapparent.

• The trust had introduced new blood sugar monitoringequipment, which was automatically calibrated daily.However, not all departments had the new equipment,for example, the ambulatory care unit used the oldblood glucose meter, which required staff to calibratethe machine daily. We found gaps in the documentation

for daily calibration, for example in January 2017 staffhad not calibrated the machine on 11 days out of 20days (not counting weekends, as the unit was notregularly open at weekends).

• Some wards had daily/weekly cleaning check lists butthis was not consistent on all wards. These were kept inthe domestics cleaning cupboard, which was locked. Itwas therefore not possible for patients or visitors to thewards to see when areas had last been cleaned.

Medicines

• Arrangements for managing medicines did not alwayskeep patients safe.

• Medicines were mostly stored securely in lockedtrolleys, were generally tidy and were securely locked tothe wall when not in use. However, we found the trolleyin the coronary care unit was not secured to the wall. Wepointed out to staff a on the unit who took immediateaction to secure the trolley. In the treatment room onWard 7B we found a drug cupboard unlocked. The wardsister locked it immediately when we pointed this out.

• Most patients had drug pods in their lockers. Therefore,staff did not use medicine trolleys but used a dressingtrolley for the medication round. We found Paracetamolloose on the trolley, which we raised with the ward sisterwho locked them away.

• Nurses were not clear what the trust policy was for thestorage of liquid medicines. We saw an opened bottle ofmorphine sulphate 10mg per 5ml in use. This medicineshould be destroyed 90 days after opening however, thedate of opening had not been recorded. Other bottles ofliquid medicine were also not annotated with the dateof opening. We also noted a bottle of Latanoprost eyedrops in use. Eye drops should be disposed of 28 daysafter opening however, these had been in use for longerthan that. We highlighted this to the nurse who removedthe eye drops. The pharmacy department recognisedthat the trust policy was not clear and as a result theguidance was being reviewed by the medicineinformation department.

• Refrigerated items were also found to have expired. Wefound an antibiotic liquid that had expired on 11January 2016 and a vial of insulin that had expired on 19January 2016. We highlighted this to staff who thendestroyed the medicines.

• Staff were required to record maximum, minimum andactual medicine refrigerator temperatures once per dayand take appropriate action when fridge temperatures

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fell outside of acceptable limits. Many wards were notcompliant with this. For example, on ward 6A, staffrecorded 28 out of 30 minimum temperatures forNovember 2016 between -1 and -4°C, which is below therecommended storage temperature for medicines(2-8°C). Staff did not record what action was taken butwe were told that there had been a problem with thethermometer. In the ambulatory care unit staff did notrecord the fridge temperature checks in line with policy.

• On ward 7A we found the lock on the medicines fridgewas broken. The ward manager told us that a new fridgewas on order and was to be delivered within a week.However, medication including vials of insulin, insulinpens, Xylocaine and Chloramphenicol were still storedin it. Fridge recordings were not in range and staff hadnot been recorded the temperatures since 5 January2017. The fridge was in a locked room but there was norisk assessment carried out to regarding the storage ofthe medicines. The ward manager told us that the wardpharmacist had allowed this and checked the fridge ona daily basis.

• Oxygen cylinders were stored in the clean utility roomon Ward 9B. However, this room was unlocked and therewas no signage on the door to indicate that the area wasused as storage for oxygen.

• We carried out spot checks on controlled drugs on somewards (Ward 9B and the coronary care unit) and foundthat these corresponded with the records. However, thedaily checking was not always completed, for example,on ward 9B the controlled drugs were not checked onfive days in the period from 1 to 25 January 2017 and inthe coronary care unit controlled drugs were notchecked on nine days in the same time period. Nursesdid not always sign the received section of controlleddrugs order book when receiving delivery of controlleddrugs. This was against the trust policy, good practiceand meant that the trust would not easily be able toinvestigate incidents involving delivery of controlleddrugs. However, the controlled drugs were stored inappropriate cupboards and the keys were separate fromthe main bunch of keys and kept on a registered nurseat all times.

• The endoscopy unit followed the ‘conscious sedation’policy for patients undergoing some endoscopyprocedures. Staff were knowledgeable about themedication that was used and had emergencyequipment which was checked daily. The unit stockedand administered controlled drugs as required. The

controlled drugs (CDs) were kept in a locked cupboardand were signed out by registered nurses. We noted thaton four entries there were not two signatures to confirmwitnessed administration. This was not in line withguidance from the national institute of clinicalexcellence (NICE CG46: controlled drugs: safe use andmanagement. April 2016). We raised this with the nursein charge who explained that drugs were removed andchecked by a trained nurse who passed it to theconsultant who administered the drug and then signedthe ‘CD book’. They stated they would take immediateaction to remind staff to follow correct procedures whenhandling CDs.

• On the respiratory ward staff used a patient groupdirection (PGD) in order to titrate the administration ofoxygen according to oxygen saturation levels.

• The nurses administered medicines in a safe, caring anddignified way. Medicine administration was tailored tothe needs of the individual patient. Nurses observedpatients taking their medicines and were patient withpeople who took a while to take their medicines andsigned the prescription chart.

• We reviewed six prescription charts on ward 6A andfound these were correctly filled in with details aboutpatient details, weight and allergies. All theprescriptions were signed and dated but we found 22blank boxes across six charts with no record of actionstaken in response to blank boxes. This meant there wasno record of the administration of the medicines, whichincluded painkillers and antibiotics. This was against a‘zero blank box’ standard set in the trust’s policy.However, we also reviewed three patient medicationcharts on the acute medical assessment unit (ACAU) andsaw that nurses administered medicines as prescribed.Nurses signed and dated when they administered oromitted medications and documented an explanation,using agreed codes, when a medicine had beenomitted.

• Registered nurses could give some medicines even ifthey were not prescribed under a patient groupdirection (PGD). The endoscopy unit had seven PDGsand there were 12 generic PDGs; Pharmacists reviewedthese directions regularly and all we looked at were indate.

• We checked medicines in the resuscitation trolleys andfound that they were tamper evident. This is in line withrecommendations by the Resuscitation council (2016)however, the guidance is not clear about the safe

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storage of intravenous fluid use in resuscitation andwhere immediate access is required. The trolleys weinspected, did not all have daily checks documented todemonstrate medicines had been checked to ensurethey were present and had not been tampered with. Thetrolleys were generally stored in areas that were busywith different staff groups around that may observe ifnon-authorised people interfered with the trolleyshowever, staff did not challenge any members of theinspection team when openly checking the trolleys.

• The medical day unit administered one cytotoxic drug.All staff who administered this drug were given trainingby a specialist oncology nurse. Competencies had to becompleted and practice observed before staff wereassessed as competent.

• Pharmacy staff, including pharmacy assistants,medicines management technicians and pharmacists,visited the wards on a planned basis from Monday toFriday. We saw the necessary medicines reconciliationto ensure that patients were taking the correctmedication.

Records

• Patient’s individual care records were not alwaysmanaged in a way that kept patients safe and did notalways comply with best practice, which meant that thepatients’ confidentiality may have been breached.Trolleys with patients’ medical records were not alwayssecured and stored in an appropriate area that ensuredthe safe keeping of medical records. For example onward 9B the trolleys did not have a digilock and werepushed into a bathroom at night, which was not locked.When we returned unannounced, we saw many patientrecords that were placed on desks and in unlockedtrolleys on the wards we visited.

• Staff accessed information about patients oncomputers. Most of the time staff logged out whenleaving the computer but we found a computer in thecoronary care unit, which was left with informationabout patients open.

• The trust had recently introduced a system forelectronic records but this had caused many teethingproblems and although it was improving, staff spoke ofongoing problems using the system. The problemsincluded issues of discharging patients of the systemand doctors had difficulties populating informationabout medicines when patients were discharged. In theambulatory care unit, the system did not allow

clinicians to look at information about patients referredby GPs. This meant, when patients entered the unit andwere assessed, they were sometimes referred to theemergency department as the needs of their conditioncould not be met safely in the ambulatory care facility.Senior management team had some concerns aboutnurses’ ability to complete real time documentation dueto other priorities. This meant that information aboutpatients would not be current and up-to-date. If theward had a high percentage of agency staff, substantivestaff completed electronic patient records on behalf ofagency nurses as agency staff did not have access to thesystem

• We reviewed the medical and nursing documentationused to assess and plan the care and treatment. Thiswas recorded on a pre-printed assessment sheet andstaff were required to tick the correct box to indicate thecare needs for each patient and that these were met.There was not an associated care plan to providedetailed guidance and instruction for staff on theindividual needs of patients. For example, staff hadidentified a patient required assistance with personalcare but there was no information about what thisassistance was or how to promote their independence.

• In a nursing handover, we heard that one patient’scondition had deteriorated and family members hadbeen informed and were on the ward supporting thepatient. However, there was no indication in theirnursing notes that their condition had deteriorated orthat they required additional nursing care to maintaintheir comfort and wellbeing.

• Staff informed us that due to working on a busy wardwith, at times, reduced numbers of registered nurses,the completion of care plan documentation was notcompleted in full. Registered nurses told us that oftenthey stayed behind after the end of their shift tocomplete the documentation. We saw this happened onward 9B during our inspection.

• The patient records in use on the acute medicalassessment unit (ACAU) were stored in the treatmentroom, which was secured with a keypad entry systemwhen unattended. However, we saw two bags ofpatients’ notes, which were awaiting collection forreturn to the medical records department. The bagscontained 11 sets of patient records whose confidentialand personal information was not protected.

• The trust undertook documentation audits and wereviewed the audit from ACUC May 2016. Staff audited

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compliance with 15 different themes includingprescription charts, filling, care plans and dischargesummaries completed. In the completed audit fromACUC (May 2016) the audit highlighted low compliancein some areas, for example, having a legible namepresent on entries in the medical care record scored64% against a target of 100%. The staff member carryingout the audit had also identified suitable action toimprove this, such as raising it in ward meetings andcommunications with medical staff. Documentationaudits formed part of the trust’s audit plan to ensureregular monitoring.

• We listened to a telephone handover about a patient’stransfer to a ward from the emergency department. Stafffollowed a set template when receiving a patient andrecorded the detail provided regarding the medicalhistory and care and treatment needs. The onus ofobtaining the information and completing the form wason the receiving ward. Staff told us they felt this processcould be more streamlined if the discharging wardhanded over the pertinent information they were awareof. They commented that going through the settemplate was time consuming and duplicatedinformation that would be contained within the carerecords accompanying the patient.

Safeguarding

• There were safeguarding systems, processes andpractices in place to keep people safe. The trustprovided safeguarding training in children’s and adultsafeguarding. The training included safeguardingawareness and safeguarding training at level two. Thetrust had a target of 90% for completion of children’sand adult safeguarding training and reported ontraining compliance across both hospitals. The trust metand exceeded its target completion for nursing staff forall four safeguarding modules and for medical staff forsafeguarding adults awareness and safeguardingchildren awareness but fell slightly below target for theLevel 2 children’s and adults safeguarding at 89.8%.

• Staff were aware of their responsibilities for identifyingand reporting safeguarding issues. Staff we spoke toknew how to report concerns about disrespectful,discriminatory or abusive behaviour or attitudesthrough the trusts’ electronic incident reporting systemconcerns. Staff were also familiar with how to escalate

concerns, sign and symptoms of female genitalmutilation (FGM). Staff knew how to make referrals tothe mental health liaison team and how to contact thecrisis team if required

• Staff knew how to make referrals to the mental healthliaison team and how to contact the crisis team ifrequired.

Mandatory training

• The trust provided mandatory training in 12 subjectsincluding basic adult life support, fire, infection controland manual handling and the trust had set a target of90% compliance. The trust reported on complianceacross both hospitals for different healthcareprofessionals. The trust met their target for medical stafffor four of the twelve modules. The remaining eightmodules were only just below the target withcompletion rates between 84% and 89.7%. The trustmet their target for nursing staff for nine of the twelvemodules. The remaining three modules were only justbelow the target with completion rates between 87%and 88.3%.

• Staff we spoke with told us they were able to attendregular mandatory training in subjects such as manualhandling, fire and infection control.


• There were processes in place to ensure consultants orsenior medical clinicians reviewed patients duringdaytime hours Monday to Friday. However, medical stafftold us patients were not always seen within therecommended 14 hours of admission because of thelarge amount of patients admitted overnight, as theemergency department in Cheltenham was closedovernight. The different specialities had consultantcover during the week from 8am to 8pm. There was adaily ‘board round’ on the wards at 8.30am, which wasattended by doctors, nurses, physiotherapists anddischarge coordinators and who discussed each patientto identify actions to support the treatment, care anddischarge planning. There was a consultant ward roundand a second ‘board round’ (staff meet to discusspatients’ condition and treatment plan away from thebedside) followed this at 3.30pm to ensure staff hadachieved all actions. The wards used a ‘red/green’action framework to ensure all patients had received apositive action to progress their recovery.

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• We spoke with medical staff on ward 4A (a short stayunit with a target to discharge or transfer patients toother medical ward within 72 hours) who described thechallenges of discharging patients because of differentmedical teams covering each day which meant therewas a lack of continuity. Junior doctors described howthey struggled to get a consultant opinion, as there wasconfusion about whom the admitting consultant wasand whose care the patient was under.

• There was a standardised approach to detectingdeteriorating patients. The trust used a recognisednational early warning score (NEWS).We reviewed 12NEWS charts on wards 8A ,8B and ACAU which had allbeen completed correctly and demonstratedappropriate escalation where the score required this.Staff had escalated appropriately and medical staff hadreviewed the patients in a timely manner. However, wealso reviewed a NEWS chart on ward 6A which waswrongly calculated and there were no documentedevidence that the elevated NEWS score had beenescalated. Auditing of NEWS scoring did not form part ofthe annual clinical improvement and audit plan(2015-2016) and we did not see a plan for 2016-2017.

• Staff we spoke to understood and followed the trustsepsis policy. We saw one completed sepsis care planand we saw that patients showing signs of sepsis wererecognised and reviewed with appropriate treatmentstarted in a timely manner and according to bestpractice.

• Whilst risks were identified, we found examples of whereactions to mitigate the risks had not always beencompleted. For example, on ward 9B, a patient wasidentified of being at risk of developing a pressure ulcer.Staff commenced a care plan with a turn chart statingthe patient needed assistance to be moved/turnedevery two to four hours. However, staff had not assistedthe patient to alter position for five and half hours orchecked for cleanliness and comfort. This was despiteevidence of previous incontinence which would increasethe risk of pressure ulcers developing. There was also norecorded evidence of mouth care documented in thecare records in the last 24 hours despite this beingidentified as a need.

• Staff in the acute assessment unit did not oftencomplete patient risk assessments and there were littleevidence of structured care planning. Staff explainedthis was because of the high turnover of patientsthroughout the day. Staff added that some patients

stayed on the unit for a short period and therefore theydid not always have time to complete all riskassessments or all of the care record. This meant therewas a risk that individual care needs would not be met ifspecific risks had not been identified.

• Staff completed an assessment of cannulae (a smallplastic tube inserted into a vein) used for intravenousmedicines or drips. They used a tool (visual infusionphlebitis (VIP) score) which they were required tocomplete daily. We looked at records and found this wasnot done consistently and we found one patient whohad a cannula inserted for four days without anydocumented evidence of assessment of the skin andvein. The presence of such invasive devices increase therisk of infection and should be checked daily.

• We noted inconsistencies within the risk assessmentsrelating to venous thromboembolism. (VTE) This is a lifethreatening condition where a blood clot forms in avein. Medical staff were required to assess the risks topatients from VTE on two occasions although we heardthat it was considered to be the joint responsibility ofthe nursing, medical and pharmacist staff to noteomissions and ensure the assessments were completed.We saw this process had been followed for somepatients but in two sets of notes on ward 9B, it had notbeen followed. On ward 4B, we checked the VTEassessment for eight patients and found medical staffhad not completed the second risk assessment for fourof the patients. The manager raised this with themedical staff immediately.

• Non-invasive ventilation (NIV) is the administration ofventilator support without using an invasive artificialairway. Staff managed NIV well at the hospital andensured patients only received this treatment withcorrect support. Staff transferred patients, who requiredNIV, from their place of care to ward 8B. This was toensure that staff with the right skills provided thisspecialised care.

Nursing staffing

• Staffing levels and skill mix did not always keep patientssafe. Staffing levels were below the planned levels andthere was a high usage of bank and agency staff.

• The trust reported their actual staffing numbers werebelow their establishment for medical care. InDecember 2016, the trust’s overall vacancy rate for Band5 nurses was 8.9% however, within general old agemedicine (GOAM) the vacancy rate for Band 5 nurses

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was 29.6%. There were no vacancies for healthcareassistants in the medical service at the time of ourinspection. Sickness level was 3.6% for registered staffand 4.9% for healthcare assistants but the turnover ratefor both registered nurses and health care assistantswas high at 15.5% for registered staff and 18.7% forhealthcare assistants. The trust was committed toaddress this and had several projects in place to supportrecruitment. There was an established recruitmentcampaign in place for all areas across the trust. Theseincluded supporting overseas nurses to achieve therequired English language qualification, engagement inrole development and working in a strategic partnershipwith the local university to ‘grow their own’ nurses.

• Almost all the wards we visited had nurse staffingvacancies and most predominantly for registerednurses. For example, ward 7A had 7.8 full timeequivalents (FTE), the cardiac wards had eight FTE, andward 6A had 4.6 FTE vacancies. Ward managers spoke ofdifficulty in recruitment of staff. Many wards hadoverseas nurses working as healthcare assistants untilthey had passed the international English languagetesting system (IELTS) and obtained their UK registrationwith the nursing and midwifery council (NMC). The trustsupported overseas nurses with course fees toencourage recruitment.

• The cardiac services had 40 beds included a coronarycare unit with eight bed spaces. The cardiac ward wasstaffed by seven registered nurses, of which three wereallocated to work in the coronary care unit during theday. However, on the night shift, this was reduced to tworegistered nurses for eight patients with varying acuity, aterm used to describe the level of care required. Weasked the specialist director about staffing levelsdepending on the acuity of the patients. They explainedthe trust reviewed nurse staffing establishment twice ayear using the ‘Hurst model’. The service did not assessor record the acuity levels of patients on each shift or ona daily basis to ensure the correct staffing was always onduty. If the nurse-in-charge felt more nurses wereneeded, to ensure safe patient care, this would beescalated. This happened for example if they hadpatients at risk of falling. We asked if any incidents hadhappened that could be attributed to inadequatestaffing levels. We were told that staff worked hard toensure the patients are kept safe and would go withouta break if the needs of the patients were such that theydeemed it unsafe to take a break.

• We spoke with the associate director of nursing, whoundertook safe staffing assessment, and asked forclarification of the acuity model they used. Theyexplained they used the association of UK universityhospitals (AUKUH) acuity and dependency tool’ twice ayear to plan the nursing establishment of the medicalservices and the trust did not measure acuity on a dailybasis. However, we asked for the latest assessment andfound the trust had last assessed staffing levels inAugust 2015. The lack of acuity assessment on ashift-to-shift basis was not in line with the guidanceoutlined in the National Quality Board: How to ensurethe right people, with the right skills, are in the rightplace at the right time. The national institute for clinicalexcellence (NICE) guidelines: Safe staffing for nursing inadult inpatient wards in acute wards (2014) alsorecommend a systematic assessment of the availablenursing staff for each shift or at least daily to ensure it isadequate to meet the actual nursing needs of patients.It further recommends so-called ‘red flag events’(incidents that may be prevented if adequate staffingwas available) are monitored; these events includesnurses missed breaks.

• The AUKUH tool describes the levels of care dependingon certain criteria and care required. Patients in acoronary care unit often require an increased level ofcare, referred to as level 2 care. Patients may receivenon-invasive ventilator support, continuous infusion ofvasoactive drugs and intravenous pain managementand therefore require closer monitoring. However, staffdid not assess on a shift-to-shift or daily basis andtherefore we could not be assured there were adequatestaffing levels particularly at nights to ensure safepatient care. The British Association of Critical Carenurses (BACCN) recommends a staff to patient of onenurse to two patients when patients acuity is at level 2.

• The trust had escalation/roster management actioncards to ensure there were adequate staff to maintainsafe care of patients. This included a clear escalationprocess and the use of a ‘decision tree’ to gainauthorisation to book agency nurses if required.

• Consultants in cardiology told us about issues relatingto the transfers of patients from Gloucester RoyalHospital to Cheltenham General Hospital for primarycardiac intervention. The private company thatprovided the transport service was unable to transportpatients with an intravenous infusion in progress unless

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there was a nurse escort, meaning medical staffdiscontinued the infusion while in transit if a nurseescort could not be found. The specific contract wasunder review at the time of our inspection

• Patients requiring non-invasive ventilation therapy (NIV)were admitted to ward 8B. Staff did not assess acuity ofthe patients to ensure sufficient staff to provide safecare. Staff risk assessed the number of patientsreceiving NIV against established staffing levels, whichallowed for three to four patients on NIV. There was aplan to develop a high care area for patients receivingNIV.

• Band 6 nurses were often working as wardco-coordinators with little or no time allocated foradministrative duties however, because of the high useof temporary staff they also felt their presence andclinical experience was needed on the wards.

• Some ward managers used secure social media apps tohelp cover shifts when these were not covered. Staffreceived this approach positively and staff did not feelobliged to come in on their days off. Managers said itworked well and in some wards, for example the acuteassessment unit, they managed to cover most of theirshifts with their own staff and mainly used agency stafffor one to one nursing of difficult to manage patients.

• Bank or agency staff were booked when patientsrequired specialist one to one support. For example, wesaw a registered mental nurse (RMN) support onepatient on the acute medical assessment unit (ACAU).This ensured that the numbers of staff on duty were notreduced. We read the Director of Nursing’s report to theboard (November 2016) which confirmed that actualstaffing of HCA care staff were over establishmentbecause of providing one to one care for patients withincreased risk of falling.

• Because of nurse staffing vacancies, we found manywards to be reliant on using agency staff to cover. Someward managers block booked agency staff they knewhad the right skills to work in the ward area wheneverpossible. For example, the ward manager on ward 4A (award for short stay and endocrinology patients) hadasked agency staff to leave previously due to lack ofskills required and now block booked known agencystaff to cover shifts on the ward. The use of agency washigh throughout the medical division with some wards

being staffed by 50% agency nurses on the days wevisited. We also looked at staff rotas and identified thatthis was a continuing trend when managers plannedrotas for the month ahead.

• Not all agency staff received a local induction on thecommencement of their shift. We spoke with an agencynurse on the cardiac wards who had never worked onthe ward before and who had not received the ‘localinduction of temporary staff’ checklist. The checklistensured an introduction to the layout of the ward andemergency procedures. However, on ward 4A wherethere was a high usage of agency staff, they includedagency staff in teaching sessions on the ward to makethem feel included in the team.

Medical staffing

• The trust supported the medical division with a 24-hourconsultant led services. During the day, consultantsworked within their speciality areas supported by juniordoctors who were ward based. Consultants andregistrars supported junior doctors (F1/F2 foundationdoctors). Junior doctors rotated across specialities andthey therefore had access to a wide range of learningopportunities throughout medicine. Out of hours, therewas a consultant on call with registrars on sitesupporting junior doctors at night. We spoke withmedical staff across the specialities and they told usthey were busy but felt well supported.

• There were some consultant vacancies in the trust. Forexample, the cardiac services had a locum covering aconsultant vacancy, which had been open for the last 12months. The service also had a consultant who wasretiring which would leave a second vacancy.Recruitment to consultant vacancies was difficult andsome consultants felt there were also additionalproblems because the workforce was divided across thetwo sites of Cheltenham General and Gloucester Royalhospitals. The hospital was actively recruiting to thevacancies.

• The acute medical assessment unit (ACAU) had sixwhole time and two part time acute medicineconsultants in post. There were junior doctors on theunit over the 24-hour period who escalated concerns toa registrar and ultimately the consultant. Nursing staffreported they had never had trouble in accessingmedical support for patients. The permanent

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consultants or colleagues from other medicalspecialities provided the consultant cover at theweekends on ACAU. A consultant led ward round tookplace each day.

• Medical staff handed over care at the end of each staffand this included information about medical patientson surgical wards. We observed a medical staffhandover and found it to be structured, comprehensiveand clear.

• We reviewed medical patients on surgical wards. Staffknew whom to contact for medical input, which was aneasy process during daytime hours. However, atweekends and overnight it was more challenging to askfor medical reviews as there was only the on-call doctorsavailable. This sometimes led to delay in assessmentand treatment of patients.


• The trust had major incident and business continuityplans in place. We spoke to senior nursing staff whoknew what action to take if a major incident took place.However, junior members of the nursing staff were notalways able to tell us about arrangements in case of amajor incident or find the policy on the trust intranet.When we asked what action they would take, they toldus they would inform the nurse-in-charge and said thatthey may be required to work elsewhere in the hospitalto help with emergency admissions. Staff were notaware of any specific training or exercises to helpprepare for major incidents.

• While we inspected the hospital there were winterpressure arrangements in place with two surgical wardsclosed or with reduced capacity for surgical patients.These wards were used as medical wards to cope withan increased number of medical admissions.

Are medical care services effective?


By effective, we mean that people’s care, treatment andsupport achieves good outcomes, promotes a goodquality of life and is based on the best available evidence.We rated effective as requires improvement because:

• The medical service did not consistently contribute toand review the effectiveness of care and treatmentthrough national audits.

• The service had a strategy to understand and improveperformance on hospital-based mortality indicators.While most specialities held mortality and morbidity(M&M) meetings monthly or quarterly we wereconcerned that not all specialties held meetingsregularly and how effectively learning was shared.

• There were some concerns about the safe transfer ofpatients receiving intravous therapy during ambulancetransfers to other hospitals.

• The trust had evidence-based care pathways but thesewere not always reviewed and updated in a timelymanner.

• Staff did not always put actions in place when patientswere at risk of malnutrition and dehydration.

• Compliance with annual appraisals was below thetrust’s target.

• There were delays in discharging patients although thiswas largely caused by factors outside of the medicalservices remit.

• Information was not always accessible to staff includinginformation about care and treatment pathways.

However:

• Staff were supported with revalidation practices.• There was a competence training and assessment

framework in place to ensure nurses were competent tocarry out extended skills.

• There was an effective framework for ‘board round’ andward rounds and included input from staff from themultidisciplinary healthcare team.

• Processes were in place to ensure consultant reviewsseven days a week.

• Staff were aware of mental capacity assessment andapplications for deprivation of liberty safeguardsapplications.


• Staff delivered patient care and treatment in line withbest evidence-based practice. We saw many examplesof medical services following best evidence-basedpractice and staff were knowledgeable about nationalguidelines and how to access the guidelines andpathways to ensure best practice was followed. Forexample, there were core care plans for patients knownto have dementia based on the Royal College ofNursing: SPACE model for dementia care in hospitals

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2012; for patient with peripherally inserted centralcatheters (PICC) care practices followed best guidancefrom the Royal Marsden NHS Trust Manual of ClinicalProcedures third edition

• The trust had a policy for assessing patients’ risk ofdeveloping a deep vein thrombosis and the prescriptionof prophylactic treatment to prevent clot formation. Thispolicy was based upon evidence-based practiceincluding guidance from the National Institute forHealth and Care Excellence (NICE): Venousthromboembolism (2015). The service monitoredcompliance and reported to the quality committee. Riskassessment compliance was 88-94% between Januaryand October 2016 against a target of 95%.

• Staff in the endoscopy unit followed guidelines forinvasive procedures in line with national safetystandards for invasive procedures (NATSIPPS). Nursesspoke of these procedures, which demonstrated theywere embedded in their practice.

• On ACAU we saw referral pathways for many differentconditions. Staff thought these were helpful to ensurethe right treatment for patients with different conditions

• We saw evidence in patient records that staff followedtreatment pathways for chest pain, based on guidancefrom the national guidance for coronary heart disease,acute kidney injury and for patients with suspected orconfirmed sepsis. However, despite the trust beingclassified as a Dr Foster outlier for mortality in patientsadmitted with cellulitis or subcutaneous skin infections,the cellulitis treatment pathway was out of date with aproposed review date of September 2015. Although thetrust concluded the increased mortality was related tomiscoding of primary cause of death, we could not beassured that patients received best evidence-based carefor cellulitis or subcutaneous skin infections.

• The cellulitis treatment pathway was out of date with aproposed review date of September 2015. However, thetrust was classified as a Dr Foster outlier for mortality inpatients admitted with cellulitis or subcutaneous skininfections. Although the trust concluded the increasedmortality was related to miscoding of primary cause ofdeath, we could not be assured that patients receivedbest evidence-based care for cellulitis or subcutaneousskin infections

• We found no documentation to show that patients withdiabetes had their feet assessed on admission tohospital as per the NICE guidance 19 and staff we spoke

to were not aware of this requirement. Staff also told usit was difficult to get the diabetic podiatrist to visitpatients on the ward although they would offer adviceover the phone.

Pain relief

• Staff assessed pain as part of undertaking observationof vital signs and documented on the national earlywarning score (NEWS) chart and on completion of the‘Gloucester Patient Profile’, which was the documentused to document care given. Patients told us nursesregularly asked them about their pain and offered thempainkillers if required. Staff used the ‘Abbey Pain Scale’tool to assess whether patients were experiencing painand when they had difficulty communicating. The trustalso had a pain management chart with a pictorial painscore assessment tool but we did not see this in use.


• Patients’ nutrition and hydration needs were not alwaysassessed and met. Staff used the Malnutrition UniversalScreening Tool (MUST) to calculate and record patients’nutritional risk. We reviewed five inpatient’s records onward 7A, where three MUST scores had not beencalculated and the appropriate actions not put in placeto support patient’s hydration and nutrition. The trustaudited compliance with MUST assessment in January2016 (published June 2016) and found that of 175audited patient records, 69% had their first assessmentcompleted on the day of their admission. 22% (38) ofthese patients these were assessed as ‘red’ with a needfor a care plan, but of these, 25 patients, (66%) did nothave a nutrition care plan in use. This meant there waslow compliance with the trust’s standards forassessment of patients’ nutrition needs and a risk to thepatient that they would not receive the nutritionalsupport required in a timely manner. Action points wereidentified and the trust planned to re-audit in December2016. However, this had not commenced at the time ofinspection.

• There were magnetic boards above each bed whereinformation/pictures were displayed about food anddrinks to suit the needs of the patient. These boardssupported staff awareness of individual patient needs.

• Patients had access to water on their bedside tables andthese were changed regularly. Staff offered patients hotdrinks and ensured drinks were within reach. The

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endoscopy unit provided refreshments (tea/coffee andbiscuits) after procedures when patients were fullyrecovered after their procedure prior to leaving thedepartment.

Patient outcomes

• The medical divisional audit lead described mortalityand morbidity (M&M) reviews conducted in the medicalservice. These occurred for about 60% of patients whodied in the trust under the care of the medical division,although an independent medical examining teamreviewed all deaths and reported to the local coroner.Following our last inspection, a framework had beendeveloped and agreed with future monitoring throughthe divisional quality report. We reviewed the medicaldivisional board report from September, October andNovember 2016 and found the new framework (astructured judgement review) was introduced inOctober 2016. Each speciality had a clinical M&M leadand every sub-speciality held M&M meetings at leastevery quarter, whilst others held M&M meetings everymonth. We did not see any evidence that meetings wereheld in cardiology and endocrinology in 2016. Most datawas collected electronically however, cardiology andendocrinology kept written notes only which were heldby the consultants. Minutes of M&M meetings showedpresentation of case notes, although we did see oneexample of notes that clearly described learningfollowing patients’ death, which was shared withcolleagues via email

• The medical service did not regularly contribute andreview the effectiveness of care and treatment throughnational audits. Information about outcomes ofpatient’s care and treatment was not routinely collect.The trust provided the latest available audit results from2016 for the Sentinel Stroke National Audit (SSNAP),theHeart Failure Audit (reflecting data from 2015) theNational Diabetes Inpatient Audit (reflecting 2015 data)and the Lung Cancer Audit (reflecting 2015data). Following the inspection, the trust providedevidence of up to date the Myocardial IschaemicNational Audit Project (MINAP)MINAP data submissioncovering 2015/16.

• The trust took part in the quarterly Sentinel StrokeNational Audit programme, however data was notavailable for each of the hospitals separately. On a scaleof A-E, where A is best treatment, the trust achievedgrade D in latest audit, between April 2016 and June

2016. The hospital showed improvements in the overallgrade having previously achieved grade E for the lastthree quarters. The trust had shown improvementsacross five patient centred domains and four teamcentred domains. The domain relating to dischargeprocesses was the only domain to shown a decline inboth patient centred and team performance. The strokeservice undertook an internal audit in September 2016,which assessed the effectiveness of an improved strokepathway. This pathway included a hyper acuteassessment unit, designated stroke consultant weeklyrota, computerised tomography (CT) scanning en-routeto wards and increased physiotherapy and occupationaltherapy support. The data demonstrated animprovement with a reduction in length of stay andimproved care for patients with reduced prevalence ofinfections.

• Results in the 2015 Heart Failure Audit were better thanthe England and Wales average for one of the four(Cardiology inpatient) relating to in-hospital care andbetter than the England and Wales average for three ofthe seven standards relating to discharge.

• Though the hospital were not currently participating inthe MINAP audit, they had scored better than theEngland average for all three metrics in the 2013/14audit, in particular the metric for non ST elevatedmyocardial infarct (‘NSTEMI’) patients who were referredfor or had angiography (including after discharge)(85.7% versus the England average of 77.9%). Theremaining two metrics scored lower than the Englandaverage.

• The hospital took part in the 2015 National DiabetesInpatient Audit. They scored better than the Englandaverage in two metrics; however they scored worse thanthe England average in 15 metrics. There was animprovement in ten metrics when compared to the 2013audit. We discussed the lack of 2016 data with aconsultant diabetologist, who explained the twoendocrinology wards in the trust had not participateddue to lack of resources to support data collection andsubmission. As a result the service was unable tobenchmark themselves against services deliveredelsewhere in the country.

• The trust participated in the 2015 Lung Cancer Audit.The proportion of patients seen by a Cancer NurseSpecialist, at 84.1%, was worse than the audit minimumstandard of 90%. Other results were not significantlydifferent from the national level, for example, the

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proportion of patients whose histologically confirmedNon-Small Cell Lung Cancer (NSCLC) receiving surgerywas 22.6%; the proportion of fit patients with advanced(NSCLC) receiving chemotherapy was 48.5%; and theproportion of patients with Small Cell Lung Cancer(SCLC) receiving chemotherapy was 61.1%.

• The trust was a ‘Dr Foster’ mortality outlier for increasedmortality rates for patients admitted with skin andsubcutaneous tissue infections. There had been 11deaths between October 2015 and March 2016compared to an expected 6.7 deaths. A thorough reviewof each patient’s notes was carried out. The trustconcluded that this was a group of patients withcomplex and multiple medical problems in whomcellulitis was incorrectly identified as the primarydiagnosis.

• The endoscopy unit had not yet achieved Joint AdvisoryGroup (JAG) accreditation. The last assessment was inApril 2016 with two key recommendations: reducewaiting times and capacity training. The trust had takenactions to ensure compliance by recruiting two nurseendoscopists and employed agency nurses to managethe waiting list. The endoscopy unit aimed to complywith all requirements and achieve accreditation byFebruary 2017.

Competent staff

• Not all staff had received an appraisal in the last year. Inthe year 2016/17, 78% of staff within the medical caredivision at the hospital had received an appraisalcompared to a trust target of 90%. Nursing staffachieved 79%, medical and dental staff 75%, alliedhealth professional 91%, healthcare assistants 78%,administration and clerical staff achieved 74%. Withoutan appraisal, learning needs may not be identified andan appropriate plan put in place to support staff todevelop their practice.

• There was no formal or regular clinical supervisionplanned or recorded for registered nursing staff withinthe medical division. However, we were shown evidenceof ad hoc supervision in personal files kept by a wardmanager.

• Medical staff told us they received regular appraisalsand offered timetabled teaching however, they wereonly able to access about 75% of the teaching offeredbecause of organisational pressures to ensure ongoingpatient care and treatment. Medical staff said studyleave varied between departments and divisions.

• Junior medical staff stated they felt supported by theirconsultants and registrars, but in some areas also feltchallenged by the number of junior doctors and thehigh turnover of patients.

• The trust had a competency assessment programme forregistered nurses, which included: nasogastric tubes,tympanic thermometer, pulse oximetry (a device used tocheck pulse and oxygen levels), male and femalecatherisation, phlebotomy (obtaining venous bloodsamples), cannulation, aseptic non-touch techniqueand the use of warming blankets. There was refreshertraining on each of these every year, which staff couldaccess via the trust intranet.

• In coronary care staff were supported to complete apost registration course (adult coronary care) run by alocal university. At the time of our inspection, 15 out of45 nurses had completed this course. Nurses completedcompetence assessments in extended skills such as‘balloon pump therapy’. The service was planning todevelop a competency based framework for all nursesas part of the induction training package.

• Staff who had recently joined the trust felt they had agood induction with a corporate induction day followedby e-learning and competence assessment in the wardarea. The induction period also included a period oftime where new staff were supernumerary and workedalongside colleagues. One healthcare assistantdescribed being rostered to work alongside a colleaguefor two weeks but this was extended, as they did not feelconfident in their role.

• Newly qualified nurses spoke of a comprehensivepreceptorship programme, which they had attendedone day a month for 12 months. We saw the inductionleaflet that staff on ward 6B used for new members ofstaff and students. This booklet included competenceassessment of ward specific objectives and extendedinformation about medicines often used to supporttreatment in patients who have suffered a stroke.

• Managers supported registered nurses through therevalidation process. Between April 2016 and November2016 463 nurses were due to revalidate in the trust ofwhich one nurse had been non-compliant withrevalidation requirements. The trust had a revalidationteam to provide workshops, one to one guidance and tosupport ward managers with discussions and

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confirmation sessions required. Individual wardmanagers monitored registered nurse revalidation in themedical division and we saw evidence of spreadsheetsmonitoring this.

• On ward 8A and 8B ward managers showed uscompetence folders for all grades of staff, with theevidence of extended clinical skills such as malecatheterisation, caring for chest drains and non-invasiveventilation (NIV). Care of tracheostomy training had tobe completed every 3 months to retain competency andhad come about as a result of learning from a seriousincident.

• Nurses in the respiratory wards could apply for postregistration courses in the management of the acutelyunwell adult, which was provided by a local university.At the time of the inspection, there were six nursesacross both sites who had completed this course.Nurses completed competence assessments inextended skills such as NIV.

• Two advanced nursing practitioners (ANP) in theambulatory care unit had completed postgraduatequalifications including the nurse prescriber course witha further two nurses working towards these.


• Effective multidisciplinary working was evident in allareas of the medical and specialist services weinspected .We observed multi-disciplinary boardmeetings where staff worked together to assess andplan ongoing care, treatment and discharge planning.All necessary staff, including those in different teamsand services was involved in assessing, planning anddelivering patient’s care and treatment.

• Staff worked well together to deliver effective care andtreatment. For example, we observed a daily meeting inthe coronary care unit where the nurse in charge, adoctor, a physiotherapist and a discharge coordinatordiscussed each of the patients to identify ‘red actions’ toensure all patients had had a positive experience inprogressing towards discharge. Staff then reviewedthese ‘red actions’ in a 3pm ‘huddle’ to ensure allactions was completed. This was in addition to anytreatment plans that consultants may have addedduring the consultant ward round. Staff felt it workedwell and kept the team focussed on agreed actions.

• Staff on the acute medical assessment unit (ACAU)communicated well with each other, with cliniciansfrom other specialities and with staff from an external

provider who were part of an integrated assessmentteam to support patient discharge. . We saw effectivecommunication with clinicians from the neurologyspeciality regarding the care and treatment of a patienton the unit. We observed this team involved with thedischarge arrangements for a patient with complex careneeds. They reviewed the patients’ medical records,liaised with the medical staff and had a tentative plan inplace for the patients discharge. However, nursing staffon the ward were not made aware of this possible andimminent discharge. This meant they may not be madeaware of plans and actions to support the dischargecould be missed.

• Staff were aware of the mental health team’s role inmanaging patients with mental health issues, how torefer to the team and how to get hold of the ‘crisis team’when needed.

• We looked at data about delayed discharge and foundthat in November 2016 the trust recorded 2015 delayeddischarges of which the three most common reasonswere: completion of assessment (876), arrangement ofcare package in patient’s own home (615) and furthernon-acute NHS care such as transfers to communityhospitals (412). Ward staff spoke of the difficulties inarranging discharge of patient who required a packageof care in the community. Patients were only assessedonce they were ‘medically fit for discharge’ however, itwould then take an additional one to two weeks toarrange care in the community, which delayeddischarge. The trust was working with the communitycare provider to address these concerns. The respiratoryward was piloting an assisted discharge scheme to helptimely discharge and included nurses visiting patients intheir home.

Seven-day services

• The service did not always meet the NHS services: sevenday service priority standards for time to first consultantreview. We looked at patients records and found that ofsome patients were not seen on a ‘post take’ round (award round by the consultant responsible for theongoing treatment of the patient) within 14 hours ofadmission. One patient was seen after 18 hours whilstanother patient was not seen by a consultant for 24hours. This meant the medical service was notcomplaint with the London Quality Standards (2013)which recommend that patients are reviewed by arelevant consultant within 14 hours of the decision to

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admit a patient to hospital. A consultant stated theservice did not meet the timeframe for post takeconsultant round largely because of the large number ofpatients admitted overnight.

• The trust did not provide a seven-day service forpatients admitted with myocardial infarction (heartattack) requiring percutaneous coronary intervention(PCI) (a procedure used to open blocked coronaryarteries). During the week, patients were transferred toCheltenham General Hospital where they had thefacilities (cardiac catheterization laboratory) to carry outPCI procedures. There were some concerns regardingthe transfer of patients requiring intravenous therapyduring the transfer. These transfers required a nurseescort for the transfer. If this could not be arranged, wewere told the intravenous therapy would bediscontinued for the duration of the transfer. This hadbeen entered on the trust risk register but remained asafety risk. At weekends and out of hours patientsrequiring PCI were transferred to other NHS trusts. Theservice had transferred 30 to 35 patients out of ours toother NHS trust in the last year. In order to iprove theservice, there were plans to combine the two cardiacunits at some point in the future.

• At the time of our inspection, there were two surgicalwards closed to surgical patients and reassigned as‘winter pressure’ wards, housing medical patients. Inaddition to this, there were 18 medical patientsadmitted to non-medical wards around the hospital.The trust had a medical outlier team consisting of aconsultant and two senior house officers who reviewedall medial outliers Monday to Friday. However, they didnot provide this service out of hours and at weekends.As a result, support was limited to the emergencyon-call team, which sometimes led to delays inreviewing patients.

• Consultants provided on site cover between 8am and8pm during the week and 8am to 5pm at weekends atboth sites except in cardiology where there was nosufficient cover to cover both days at both sites. Therewas also a second consultant acute physician on duty atGloucester Royal Hospital at weekends from 9am to1pm to review new patients on winter pressure wardsand medical patients admitted to surgical wards. At allother times consultants were available via on callarrangements out of hours.

• Pharmacist or pharmacist technicians visited the wardsevery day Monday to Friday. The pharmacy was open onSaturdays for staff to order specific medication forpatients admitted out of hours. On Sundays, only on callpharmacy support was available.

• Staff had access to support and advice from the mentalhealth liaison team and the older peoples mental healthliaison team seven days a week as well as

• Physiotherapy and occupational therapy for patientswho had suffered a stroke was available Monday toFriday where each patient received six sessions a weekover five days. Staff felt that a seven-day service wouldhelp to discharge patients earlier.

• The endoscopy unit provided services seven days aweek although there was reduced capacity atweekends. Staff were on call to cover out of hoursemergencies and there was consultant on-call cover 24hours per day in line with recommendations by theNational Confidential Enquiry into Patient outcome andDeath (NCEPOD) 2015: Time to get control guidance.

• Patients had access to the ambulatory care unit Mondayto Friday from 8 am to 6pm. The hospital employed amedical locum registrar on a long-term contract whowas allocated to the unit during opening hours. Theywere supported by an acute consultant physicianbetween 10am and 6pm. On occasions at weekends andbank holidays the unit was also open; however this wasdependant on the ability to provide sufficient staff. Attimes, when the unit was open over the weekend,medical staff from the emergency department wereallocated to cover the unit.


• The trust had effective processes in place to reviewpatients every day. We asked about arrangements forward rounds, which varied a little from ward to ward. Onward 9B there were effective processes for consultantward rounds every day Monday to Friday, withconsultants reviewing new admissions or very sickpatients over the weekend. There was also a ‘boardround’ every morning where allied health professionalsalso attended and at 3pm, another meeting (known as ahuddle’) where staff reviewed achievements of plannedactions for the day. To do this they used a ‘red/greenday’ tool to ensure all patients had positive interactionsand planned care was achieved for the day. The trustaudited the effectiveness of the board rounds to include

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data, such as who was present, the length of time, theuse of red/green framework and actions to helpdischarge planning; however, it was not clear how theservice planned to use this information.

• We observed handover between nursing staff at thecommencement of the late shift. During one handover,staff that were coming onto shift and in attendance ofthe handover were interrupted by patients and otherstaff. This meant that they missed part of the handover,which caused a risk of them not being aware of vitalinformation for patients they were caring for

• The medical service sent care summaries to GPs ondischarge to ensure continuing care. The trust auditedpatient discharge summaries sent to GPs within 24hours. In October 2016, the result across the trustexceeded the target of 85% with 88.2% of summariesbeing sent to GPs within 24 hours. Staff also gavepatients a copy of the discharge summaries when theyleft to ensure they had up-to-date information abouttheir health in case of emergencies.

• However, staff did not always have access to electronicinformation about care. We spoke with a band 5 staffnurse who had recently returned from maternity leave.They had not had any induction/supernumerary time toupdate themselves with any changes for exampleresetting computer passwords. This meant they couldnot access information about patients, policies orupdates unless a colleague logged them into acomputer. The trust used a large proportion of agencystaff to ensure adequate staffing, however agencynurses did not have access to electronic resourcesincluding guidance about care and medicines. We askedwhat the impact of this was, but were told agency staffalways worked alongside permanent members of staffwho supported them to access the information theyrequired.

• Information about resuscitation status was kept in thefront of medical notes. We reviewed three ‘do notattempt cardiac pulmonary resuscitation’ (DNACPR)forms and found that these were generally correctlycompleted although it was not always recorded thatdiscussion with the patient and their next of kin/familyhad taken place even though this was ticked on theform. There were four different DNACPR decisions,which meant varying medical input would be but inplace, if a patient’s condition deteriorated. In mostcases, staff communicated these decisions at handoversand when patients moved between departments.

• Medical records were in a paper format and obtainedfrom the medical records department. Staff commentedthese arrived promptly when requested.

• The trust introduced a new electronic patient recordsystem in December 2016. This had caused problems forstaff initially with the inability to access the records citedas a concern. Patient feedback on the acute medicalassessment unit (ACAU) within a completed family andfriends survey had identified that the new recordssystem had caused chaos on the unit whilst they were apatient in December 2016.We discussed this with staffwho stated there had been issues with the electronicpatient record system but the system was improving.


• Patients’ consent to care and treatment was sought inline with legislation and guidance. Staff were aware ofthe importance of obtaining consent before any care ortreatment interventions. We observed a therapy sessionon ward 6B where staff obtained verbal consent fromthe patient before commencing the session.

• Staff received training in awareness of ‘mental capacityact’ (MCA) and ‘deprivation of liberty safeguards’ (DOLS).Training compliance for these topics were at 88.9% forMCA training and 88.9% compliance for DOLS trainingfor all staff (medical staff, nurses, healthcare assistantsand administration support staff) within medical care(October 2016). The compliance fell slightly below thetrust’s target at 90%. However, 90.8% of nursing staffand 90.6% of medical staff had completed both MCAand DOLS training.

• Staff we spoke to had an understanding of the MentalCapacity Act 2005, Deprivation of Liberty Safeguards andpatient consent. Doctors completed mental capacityassessments for patients. We reviewed ‘do not attemptresuscitation’ forms and found that where applicablethere was evidence that medical staff had assessed thepatients’ mental capacity. However, we reviewed patientrecords and noticed that a mental capacity assessmenthad not been undertaken and recorded for one patientwho was identified as lacking mental capacity.

• Senior nurses were knowledgeable about the processesinvolved with DOLS applications and when theapplications should be reviewed and renewed ifapplicable. Junior nurses were aware of the mentalcapacity assessment and DOLS but said they would askmore senior nurses for help and advice if they had to

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deal with a DOLS application, as this did not happenregularly. Staff also told us they could access supportform a social worker if required when completing DOLSapplications. We reviewed the completed applicationpaperwork for one patient and found this to hold allrelevant information.

Are medical care services caring?

Good –––

By caring, we mean that staff involve and treat peoplewith compassion, kindness, dignity and respect. We ratedcaring as good because:

• Patients were positive about the way they were treatedand cared for in the medical wards.

• We observed staff treat patients with kindness, dignity,respect and compassion.

• Patients praised staff for providing further informationwhen asked.

• We observed caring interactions from staff whenpatients showed signs of being in distress

However:

• The discharge lounge was a mixed sex unit and did nothave curtains to screen individual chairs and provideprivacy for patients in their pyjamas or when assistancewas needed with personal care needs.

• Information about patients was not always keptconfidential.

• Whilst responses to the friends and family test waspositive, response rates were low.

Compassionate care

• Patients were treated with kindness, dignity, respect andcompassion while they received care and treatment. Weobserved pleasant interactions between staff andpatients and witnessed sensitive and compassionatehandling of discussions with patients about ‘do notresuscitate’ status.

• We spoke with patients who told us that nurses weregood. Some said that nurses could be stern and bluntbut that they quite liked that approach.

• We observed many examples of how staff sought tomaintain patient’s privacy and dignity, such as staffpulling curtains around the bed space when assistingwith personal hygiene or other care interventions.

However, the discharge lounge was a mixed sex unit anddid not have curtains to screen individual chairs andprovide privacy for patients in their pyjamas or whenassistance was needed with personal care needs.

• The Friends and Family Test response rate for medicalcare at the trust was 14%, which was worse than theEngland average of 25% between November 2015 andOctober 2016. The response rate at GloucestershireRoyal Hospital was just 13%. We looked at responsesfrom October 2016 and found that some wards scored100% but the number of patients who had completedthe questionnaire were low at between three to sixpeople. The cardiac wards had received feedback from71 patients and scored 96% whereas the Gallery wardscored 83% from 12 responses and the acuteassessment unit (ACUA) scored 85% from 26 responses.

• The trust’s average score for privacy, dignity andwellbeing from a patient led assessment of the careenvironment (PLACE, 2016) was 80.7% against anational average of 84.2%. Seven medical wards wereincluded and the highest score was Ward 6A with a scoreof 96.7% while the lowest score was 66.7% on the acutemedical assessment unit (ACUA) unit.

• Information relating to previous patient experiences waslocated on noticeboards on the wards. Patients wereasked to complete surveys following their stay on theward. For example, the outcome from the surveys onWard 9B showed that in December 2016, 75% of thosecompleting the survey would recommend the ward. InNovember, 86% recommended the ward and in October2016, 100% of patients completing the survey madepositive comments. A common theme from the surveysrelated to positive comments about the staff attitudetowards patients.

• Information on the ACAU showed that in December2016, 14 completed surveys had been received, with93% of patients saying they would recommend the unit.Comments included a good staff attitude and patientsthought that the nurses and doctors were professional.

• Patients discharged from ward 7A between January andMarch 2016 were sent a questionnaire asking abouttheir experiences. It was not clear how many patientstook part and the results varied from the least positiveexperience with only 24% of patients said they were notable to find a member of staff to talk to about their

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worries or fears. The most positive responses related toplanning, where 83% of patients said that staffdiscussed whether they might need any further healthor social care services after leaving hospital.

Understanding and involvement of patients andthose close to them

• Patients and those close to them were involved aspartners in their care. We spoke with patients whopraised the communication skills of the staff when theyneeded further information or asked questions. Theytold us that they were involved in decision making withdoctors and nurses about their care and treatment.

• A ward manager gave us an example of meeting apatient’s individual needs; a patient’s only relative livedin Australia. Staff organised a password with thepatient’s permission, so staff could discuss progress anddischarge planning with them.

• Some patients told us they were given conflictinginformation about their treatment from differentconsultants. Some patients felt concerned for otherpatients who were unable to communicate and felt staffwere not well informed of patient’s needs

• Some patients expressed frustration that they had torepeat themselves a lot for example information aboutspecific instructions about personal care needs, as therewere so many different staff.

Emotional support

• Patients received the support they needed to copeemotionally with their care, treatment or condition. Weobserved caring interactions from staff when patientsshowed signs of being in distress. For example, while wewere shown around a ward, we noticed a patient whowas visibly upset and the sister immediately went to thepatient to listen to their concern and reason for beingupset.

• We spoke with a patient in the cardiac ward who hadwitnessed the sudden deterioration of another patientin the night. They spoke of the professionalism of theteam of doctors and nurses assembled to care and treatthe patient and of the support the nurses offered to theother patients in the same bay. Staff were described askind and compassionate in the way they handled thesituation.

• However, some patients expressed they were beginningto feel very low in mood or depressed because of theuncertainty about when they could go home, theboredom and the restricted opportunities for exercisingand moving around.

Are medical care services responsive?


By responsive, we mean that services are organised sothat they meet people’s needs. We rated responsive asrequires improvement because:

• The delivery of cardiology services did not meet theneeds of the local population.

• There were delays to discharges, which meant patientflow through the hospital was compromised.

• There was a waiting list for patients requiring anendoscopic procedure.

• The environment did not meet the needs of patientswith dementia.

• The trust reported 32 breaches of mixed sexaccommodation in the period from January 2016 toOctober 2016 of which 11 were in the acute medicaladmissions unit.

• The service was not always compliant with theaccessible information standards and informationleaflets were not readily available for patients for whomEnglish was not their first language.

However:

• The trust’s referral to treatment time (RTT) for admittedpathways for medical services has been better than theEngland overall performance.

• Staff knew how to arrange for translation services ifrequired.

• Complaints were dealt with in a timely manner andthere was evidence of change of practice as a result.


• Medical service were planned and delivered to meet theneeds of people. However, senior staff in cardiologyservices spoke about a change in the delivery of care, asthis did not meet the needs of local people. Cardiacservices were situated in both locations however; theservice provision did not always meet the needs of

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patients. Patients were admitted to the cardiac wards atGloucester Royal Hospital from the emergencydepartment but if they required percutaneous coronaryintervention (PCI) (a procedure used to restore theblood flow in the heart), they were transferred from theemergency department to Cheltenham General Hospitalto the cardiac catheterisation laboratory (cath lab).However, the cath lab in Cheltenham was not openseven days a week and the emergency department inCheltenham did not admitted patients brought in byambulance from 8pm. This meant that patients weretransferred to other NHS hospital trusts

• There was daily teleconference with commissioners, thelocal authority, the ambulance service and bothhospital locations to discuss the availability of beds andany patient flow issues. There was a separateteleconference where staff discussed bed availabilityand the potential number of discharges, as well as anystaffing issues that may compromise capacity.

• Specialist respiratory nurses worked with thecommunity healthcare provider as a link to enablepatients with long-term respiratory disease to stay intheir home or help facilitate early discharge.

• The renal service identified a need within children andyoung person’s population for a transition clinic fromchildren’s to adult services and Ward 7B planned to starta new monthly transition clinic from January 2017.

• However, we spoke with consultants in the stroke careteam about the results of the Sentinal stoke audit. Theyidentified that there were delays in timely interventionbecause they were not always able to admit patients tothe stroke unit in a timely manner. Often the reason forthis was, that they were not allowed to ‘ring fence’ bedsfor emergency admission of patients, who had suffereda stroke.

Average length of stay

• Between April 2015 and March 2016, at GloucestershireRoyal Hospital, the average length of stay for electivepatients was 8.2 days (higher than the England average)and 6.4 days for non-elective patients (lower than theaverage). Neurology had the highest average length ofstay at 13.3 days compared to the England average of5.8 days, followed by non-Geriatric Medicine 12.6 daysversus the England average of 9.8 days.

• However, between March 2015 and February 2016,patients had a lower than expected risk of readmissionfor the top three specialties for all non-elective andelective admissions.

Access and flow

• The trust had processes in place to monitor access andflow issue during the day. The site management teamheld meetings at intervals throughout the day to reviewand assist with the flow of patients through the hospital.The frequency of the meetings during the day wasdependent on the status of the hospital. For example,when the hospital was in ‘black escalation’ whichindicated there were few or no free beds but patientsstill in the emergency department waiting for beds,meetings were more frequent. A policy was in place toguide and inform staff on the site management meetingschedules, who needed to attend which meetings andthe responsibilities of certain staff at the meetingsdepending on the escalation status. These were referredto as action cards. Meetings focused on potentialpatient discharges and any support needed to achievethis.

• The matrons within the medical division, held a furtherand separate telecom each morning to assess thestaffing levels and skill mix on each ward. This enabledthem to review the acuity of patients on the medicalwards and establish if there were any problems withplanned discharges. This helped to assist with the flowof patients through the hospital.

• The trust had an occupancy rate of 92-94% betweenJanuary and June 2016. It is recognised that a bedoccupancy rate above 85% may affect the flow ofpatients from admission to discharge and affect thequality of care and treatment. The board report fromNovember 2016 showed there were 2,355 bed daysoccupied by patients deemed medically fit for dischargein October 2016. In the same month, there were also 45delayed discharges.

• The trust had a single point of access strategy, whichmeant that all patients were admitted via theemergency department. From there, patients wereallocated beds in suitable ward areas, of which theacute assessment unit (ACUA) was often the ward ofchoice for further assessment of care and treatmentrequirements. Patients were either discharged or movedto beds within the most suitable specialities for theircondition once a further assessment was completed.

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The unit admitted on average 30-47 patients per day.Between September 2015 and August 2016 the trust had16,643 patient admissions. The trust monitored howmany times patients moved wards during an admission.In the same period, 4,722 patients moved wards once,974 moved twice, 772 moved three times and 254patients moved wards more than four times during theadmission to medical services in Gloucester RoyalHospital.

• Patients were admitted from the emergencydepartment throughout the 24-hour period including atnight. At times staff were also required to transferpatients from the ACAU to other wards at night to ensurebeds were available. We asked the staff if there was aprotocol to reduce the movement of patients unlessnecessary during the night but were told there wasn’t,with the exception of patients being moved to externalcare providers. However, we noted two patients in thespace of one week in January 2017 had been moved toexternal hospitals at 11pm. The trust audited how oftenpatients were moved after 10pm and reported anaverage of 496 patients per month who were movedfrom AUCA to other wards after 10pm. Documentationon the ACAU identified that patients were oftentransferred from ED in groups during the evenings ratherthan steadily during the day. This affected theavailability of nurses to admit the patient to the unit andmove patients during the evening and night to be ableto provide a bed.

• The ambulatory care unit received patients alsoreceived patients via GP referrals. The aim was tooperate as ‘one stop services’ and therefore the unit hadtwo designated computerised tomography (CT)scanning slots daily including Saturdays. The unittreated 15-30 patients a day but they were hoping toexpand this by moving the location of the service to anarea closer to the emergency department. This wouldallow them to accept patients with for example seizuresor chest pain. The unit was open Monday to Friday from8am to 6pm however; they did not accept referrals after4pm to ensure all patients had completed interventionsor treatment by 6pm. If patients remained on the unitbeyond that time, nursing staff stayed later until allpatients had left the unit. The ambulatory care unitspoke of some frustration about issues with the newelectronic care records system. The system preventedthem from accessing information about patientsreferred by GPs. As a result, patients sometimes arrived

at the unit and were assessed, but then referred to theemergency department as the patient’s condition couldnot be treated as an ambulatory admission. This meantthat access to treatment was sometimes delayed forpatients.

• Between November 2015 and October 2016, the trust’sreferral to treatment time (RTT) for admitted pathwaysfor medical services has been better than the Englandoverall performance. The latest figures for October 2016showed 93% of this group of patients were treatedwithin 18 weeks compared with the England average of90%. The trust’s performance had been consistentlybetter than or in line with the England average with theexception of July 2016 when their performance fellslightly below the average.

• The discharge lounge was open Monday to Friday from7.45 am to 8 pm but wanted to expand to ‘seven dayservice’ to help patient discharge over the weekend.Staff in the discharge lounge spoke of increasingdemands on the service with the numbers of patientsincreasing and included patients attendingappointments in the medical day unit and ambulatoryemergency are unit. The impact of increasing numbersmeant the discharge lounge often stayed open until9pm although officially it closed at 8pm. Staff stayedlate to ensure patients were care for. This was largelydue to delayed transport of patients to their homes.

• We met discharge coordinators on the wards where theytook part in ‘board rounds’ to help facilitate timelydischarge. However, patients were only assessed oncethey were declared medically fit for discharge. Thismeant patients may stay in hospital longer while waitingfor care packages to be arranged or placement in acommunity health facility. On one day (25 Jan 2017)during our inspection, there were 130 patients medicallyfit for discharge awaiting safe discharge.

• The trust had appointed two non-medical endoscopists(these are not medical doctors by background but oftennurses who receive specialist training and supervision)to help address the backlog of patients waiting. As aresult, the number of patients waiting for a procedurehad fallen from 600 to 428 in November 2016


• The service took account of the needs of differentpeople, including those in vulnerable circumstances. Forexample, staff told us there was an excellent language

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translation service provided by phone, or face-to-faceinterpreters could be booked in advance. We were toldthe trust priority was not to use staff members asinterpreters.

• Staff in the ambulatory care unit administeredintravenous medication such as antibiotics daily topatients for the duration of their prescribed course.Patients could go home and did not need to beadmitted for treatment. Staff gave patients a choicewhether they wanted to go home with the cannula (asmall tube place in a vein) in situ or have a cannulainserted every day. There was a leaflet for patientschoosing to go home with the cannula in situ; however,staff did not always give this out to patients. We askedhow staff risk assessed patients for their suitability toleave with the cannula in site and found there was nopolicy to guide staff but they used their intuition.

• The trust had a dementia strategy and introduced‘dementia champions’ on many wards. The strategyoutlined actions to provide dementia friendly care,provide processes to assess and refer patients withdementia and ensure staff received training in caring forpatients with dementia.

• Clinical guidelines produced by the national institute forclinical excellence (NICE, CG42 (2006, last updatedSeptember 2016)) recommends that all staff have accessto dementia training. After the inspection we asked forinformation about how many staff had attendedtraining and found 84% of nursing staff were 84% hadattended dementia awareness level 2. However, only25% of medical staff had attended and there was nofigures given to demonstrate attendance for alliedhealth professionals.

• The trust had a dementia strategy, which included avision to enhance the healing environment. However,we did not find the room used for a dementia supportgroup on ward 9B, to be dementia friendly. The roomwas clinical in appearance with little colour. There werenoticeboards in one corner of the room that thatcontained clinical information for staff regardingdementia. There were activities available for patientssuch as jigsaws and craft materials. In a patient-ledassessment of the care environment (PLACE, 2016), thescore for dementia awareness on medical wards rangedfrom 46 % on ward 8A to 96% in the cardiology ward.

• We spoke with a healthcare assistant who was also a‘dementia champion’. They told us about activity groupsfor patients with dementia on ward 9B, which providedcognitive stimulation therapy (CST) by facilitating artsand craft activities, bingo, and work with a psychiatrist.

• Dementia leads spoke of plans to roll the dementiagroup work out to other wards and other initiatives tohelp and support patients with dementia. Theseincluded the use of ‘twiddle muffs’ (single use) whichhelped to stop patients with dementia pull at infusionlines or catheters which could cause harm. Staff alsotold us about ‘John’s campaign,’ which was an initiativeto invite relatives of patients with dementia to come inoutside of normal visiting hours to assist with mealtimes and personal care if appropriate.

• The trust was in the process of introducing ‘this is me’diaries for patients with dementia, where relatives couldadd information about the patient to help inform nursesand other healthcare professionals of specific likes anddislikes of the patient which would promoteunderstanding and communication. Most wards hadlarge dementia friendly signage. Staff told us that theyare considering purchasing large clocks for the wards forthe visually impaired though we did not see any in anyclinical areas we visited.

• The acute medical assessment unit (ACUA) reported 11incidents of mixed sex breaches between October 2015and August 2016. This meant that patients had receivedcare in an environment that could have compromisedtheir dignity and privacy. The trust reported 32 breachesof mixed sex accommodation in the period fromJanuary 2016 to October 2016.

• Patients commented on how busy and noisy wardswere. They told us bells could ring for up to 30 minutesbefore they were answered, but they could not be sure itwas always the same bell. During the inspection wefound staff usually answered the call bell within threerings. However, on ward 8A, the call bell for a patientrang for 10 minutes and was not answered until weasked the ward manager for someone to answer thebell. Staff on ward 7A supplied newly admitted patientswith an admission pack which included an eye maskand ear plugs however, there did not seem to be a planto investigate the reason for the need to supply theseand to reduce noise and light at night.

• Staff knew about arrangements for people who neededa translation service. However, we could find noevidence of patient information leaflets in other

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languages on the wards. Staff did not consistentlyobtain information about people’s communicationneeds, which did not comply with the informationstandards. The Accessible Information Standards (2015)directs and defines a specific and consistent approachto identifying, recording, flagging, sharing and meetinginformation and communication needs of patients,where those are related to a disability, impairment orsensory loss. While the trust used visual reminders toalert staff to additional care or communication needs,we found that the assessment documentation was notconsistently completed.

• Additional support was available to ward staff whencaring for patients with a learning disability Staff knewhow to access the Learning Disability nurse who wasinvolved in discharge planning for patients with learningdisability. We observed staff discuss the care needs of apatient with a learning disability at length during amedical handover to ensure the patient’s involvement indecision-making and care and treatment wasappropriate. The trust employed two learning disabilitynurses and had access to the mental health crisis teamvia electronic referrals.

• The patients view on the hospital food was good. Mostpatients felt the portion size and menu choice was morethan sufficient, and food was described as enjoyable.However, a patient-led assessment of the careenvironment (PLACE) audit from 2016 included anassessment of food on the acute medical assessmentunit (AUCA), ward 6B and cardiology ward CW1; theresults scored 64% to 84% for satisfaction from patients.Patients could access food late in the evening as staffhad access to sandwiches and snacks. We observednotices for protected mealtimes on the wards andflexible visiting for carers to come in and feed theirrelatives.

• Staff in the discharge lounge told us that medicines totake home did not always arrive with the patient fromthe wards. This meant that administration of medicinesto patients were sometimes delayed as the dischargelounge did not keep any stock medicines.

• We were told the transition from paediatric to adultfacilities was not very good and. Staff on the renal wardtold us they were about to start a new monthly clinic forthe transition process. They had only had one clinic so itwas too really to tell how successful it was.


• People’s concerns and complaint were listened andresponded to and used to improve the quality of care.

• Between November 2015 and October 2015 there were109 complaints about medical care across the trust. Thetrust took an average of 40 working days to investigateand close complaints. This was not in line with theircomplaints policy, which states 95% of cases should beresponded to within 35 working days. Patient care wasthe most complained about theme with 34 complaints,followed by admission & discharges with 31 complaints.The profession ‘nursing’ received 64 complaints. AtGloucestershire Royal Hospital, there were 78complaints of which patient care received the highestnumber of complaints, 24 (31%).

• On ward 8A, we saw a ‘niggle board’ for patients andrelatives to write on informing the ward what niggledthem. A patient wrote that he was unable to use thehard buttons of the nurse call system. The ward thenpurchased two soft button call bells to ease theproblem.

Are medical care services well-led?


By well-led, we mean that the leadership, managementand governance of the organisation assures the deliveryof high-quality person-centred care, support learning andinnovation, and promotes an open and fair culture. Werated well-led as requiring improvement because:

• There was a lack of overview and governance aroundmortality and morbidity (M&M) meetings.

• There was a lack of understanding of the risk to safepatient care, the acuity of patients on daily basis have.

• Risks registered on the risk register were not alwaysaligned with risks in the service.

• There was a limited approach to obtaining the views ofpatients and their relatives.

However:

• The trust had a clear vision and some specialities withinthe medical division had a vision to expand and improveservices.

• The trust had a risk register and the medical divisionhad a separate risk register; management appeared tofollow up identified risks with mitigating actions.

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• There were processes in place to review incidents andensure learning was shared throughout the trust.


• Leadership of the medical division encouragedopenness and promoted good quality care. However,we found there had been limited progress made sinceour last inspection in 2015.

• Divisional leads told us there was now an establishedmanagement team and that this provided stability.There was an organised management structure, whichwas focussed with clear direction and people were heldto account. However, some staff had not met or seen thenew chief executive in their ward area and some stafffelt only senior managers engaged with the executiveteam.

• Managers appeared competent, enthusiastic andknowledgeable about their services and well informedabout the wider challenges within the medical division.Managers felt well supported by the matrons and weobserved matrons visiting many wards during the timeof the inspection.

• Nursing staff told us managers were very accessible andoperated an ‘open door’ policy Senior ward nurses andward managers felt well supported by matrons. Staff feltthey could raise concerns about care to managers ormatrons if required.

• Medical staff told they felt well supported by seniormedical staff and consultants


• The Trust’s vision was to provide the best care foreveryone and spoke of five pillars of transformation toachieve this. These included, building capacity andcapability, improving patient flow, modernising theirhospitals, working in partnership and delivering bestvalue. Staff were aware of the trust’s values andinformation was displayed inwards and corridors.

• We spoke to some service leads about their vision forthe service:▪ The stroke service had a vision for the development

of stroke service including seven day service(thrombolysis) and hoped to achieve better auditresults.

▪ The specialist director of cardiac services, the wardmanager and consultants all spoke of plans tocombine cardiac services across both GloucesterRoyal and Cheltenham General Hospital onto one

location. They felt this would improve patient careand treatment, help to recruit and retain staff andenable consistency in training opportunities fornurses.

• Staff were aware of plans to improve service delivery.More senior nurses demonstrated a more in depthawareness but staff were unsure about the time scalefor these changes.

• Ward 6B had an introduction booklet, which they usedfor all new staff and students. The ward’s missionstatement/vision and strategy was clear describedwithin the booklet.


• The trust had a governance framework that set outresponsibilities for managing quality, performance andrisks. There was a clear divisional structure and monthlyquality and performance committee meetings andmonthly quality reports. These were presented to boardmeetings for discussion about quality and performance.

• The trust held morbidity and mortality (M&M) meetingsto identify learning and formulate actions to improvecare and treatment of patients. However, there was alack of overview and governance of how often thereviews took place and we were not assured that thetrust complied with their M&M meeting schedule. Wereviewed which M&M meetings were held in the last 12months. There were regular meetings in most servicesbut we did not see any reference to a cardiology M&Mmeeting held in 2016. Where meetings were heldlearning points were identified and shared via emailwith colleagues However, in the neurology/strokeservice only two meetings were held in 2016 and noactions or learning was identified. This led us toconclude that meetings were not held regularly orconsistently applied across all medical specialities.

• The trust with had an annual clinical Improvement andaudit plan 2015-2016 for local and national audits. Thisincluded venous thrombo-prophylaxis, confusionproforma/dementia screening, acute kidney injury andthe escalation policy/DNACPR. Audit results weresubmitted to the strategic clinical improvement andaudit committee. We asked for the current audit plan aspart of the data obtained prior to the inspection. Theaudit plan in use was that dated 2015-16.

• There was a trust risk register and a medical division riskregister with identified risk which could affect the

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effectiveness or safety of the service. The risk register forthe medical division was maintained electronically withrisks added by the general managers and matrons. Wefollowed up two of the listed entries to the risk registerto assess the effectiveness of actions taken to reducethe risks.

• Risk of harm to patients due to inadequate numbers ofskilled/trained nursing staff. Nursing staff vacancieswere highlighted in almost all conversations we hadwith managers and other clinical staff. The trust hadplans in place to increase recruitment and retention andthe director of nursing submitted a monthly report tothe board. However, there was a lack of understandingof the impact greater acuity had on safe nursing staffinglevels to keep patients safe. The annual assessment ofnursing staff establishment was not adequate to ensuresafe staffing levels on a day-to-day basis.

• Harm to patients due to errors in the prescribing ofinsulin. We spoke with a consultant about actions takento improve practice. They told us a specific insulin chartallowing daily adjustments had been introduced andthat these were audited; in addition, plans were indiscussion about the feasibility of introducing specificinsulin rounds across the hospital.

• We spoke with ward managers and consultants aboutissues that may be identified as a risk to either the safetyof the patients or the effectiveness of the service. Theyspoke with confidence about the role of the risk registerand how this fed into a robust governance framework.However, they did not always add risks which when weasked they acknowledged should be on the risk register.This meant that there was not a service level ororganisation overview of risks to patients’ safety orservice delivery.

• The medical division health and safety committee metevery month to review any issues that had arisen. Thecommittee submitted a report every six months to thetrust wide health and safety committee. This included,amongst others, incidents of needle stick injuries, falls,spillages, infection control and stress management. Thehealth and safety committee also presented informationfor staff each month on a relevant topic, the most recentbeing stress. Staff were signposted to information onhow to deal with stress, such as the trust policy and achecklist for teams to assess stress levels.

• The clinical risk lead reviewed reported incidents fromthe medical services. Any potential serious incidentswere discussed with the ward staff and additional

information gathered. Serious incidents were reviewedat a scoping meeting and an investigator allocated tocarry out an investigation of the circumstances andoutcomes. Incidents that were not considered to beserious incidents were investigated appropriately andactions identified and taken. Feedback was provided tothe original reporter of the incident.

• Trends and patterns of incidents were analysed by theclinical risk team and reported to the medicinedivisional leads. The top five incidents reported withinthe medicine division were falls, pressure damage,violence and aggression, medicine errors and staffing.

• The clinical risk team prepared reports, which theyshared with senior staff in meetings. Flyers withinformation about learning from specific incidents weredistributed to staff by email. The most recent flyer hadinformed staff that there was a concern about the lackof escalation following deteriorating NEWS scores andthe action that was required to be taken.

• When staff reported an incident on the electronicincident recording system, they received an emailacknowledging and thanking them. Once aninvestigation was complete, staff also received a reportof any actions or outcomes associated with the incident.


• The senior divisional management team felt there was ashared vision and that they were a part of a strong teamand part of the solution. The divisional managementteam felt positive about plans for the future.

• Staff mostly felt positive about working for the hospitalalthough all staff said they were always very busy withhigh volume of patients, staff shortages and the highusage of temporary staff.

• Staff knew how to escalate concerns includingwhistleblowing and knew how to access the policy ifrequired.

• We observed good working relationships betweenmanagers and staff on the wards. Managers spokehighly of the commitment of staff and stated they wereproud of the teamwork, care and compassiondemonstrated by staff.

Public engagement

• The trust encouraged patients to comment on the careand treatment they had received in the medical servicesthrough the friends and family test, however the

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response rate was generally low at about 25%. Therewere posters displayed in ward areas encouragingpatients and their relatives to complete the test and thewards displayed feedback from these.

• Patients from ward 7A who completed a survey aboutcare, were invited to join the staff at a focus group tohelp draw up action plans to address the three mainareas that the survey highlighted as areas whereimprovements could be made. As a result, the wardintroduced admission packs including eye masks andear plugs, and a new ‘It’s OK to ask’ campaignencouraging patients to ask about their care andtreatment was due to start in the next few weeks. It wastoo early to evaluate the effectiveness of this campaign.

Staff engagement

• The trust undertook a staff survey in 2016 and from theresults an action plan was formulated to help improvestaff engagement. Amongst the actions identified for themedical division were: re-branding and re-introductionof staff forums, re-launch of 'walk abouts' at specialityand divisional level and to increase networkingincluding exploration of safe use of social networkingapps.

• However, although actions were identified withtimescales and responsibility assigned to different

people it was unclear how effective these actions were.For example, we did not meet with any staff who hadattended a staff forum in the medical division and staffwere not sure when these were happening.

• Staff were generally enthusiastic about their workdespite the business of the hospital and felt they wouldbe supported to develop services. For example, a nursesuggested to the tissue viability specialist nurse that itwould be useful to have a designated trolley for wounddressings and had helped to set this up. The manageron ward 9B promoted an ‘ideas board’ to encouragestaff to participate in and take ownership of serviceimprovement initiatives.


• Falls assessment stickers had been introduced toimprove assessment and documentation. The stickerprompted medical staff to make a clear managementplan to follow up and review falls prevention. Thisproject also included a post fall assessment protocoland a falls register both of which were included in thefalls prevention care bundle. The use of the stickers hadbeen audited and results demonstrated an increase inpost fall assessment of signs of fractures, head injuryand neurological assessments.

Medicalcare






Overall

Information about the serviceSurgical services provided by Gloucestershire HospitalsNHS Foundation Trust are carried out at two hospital sites:Gloucestershire Royal Hospital and Cheltenham GeneralHospital. Services provided at Cheltenham GeneralHospital are reported on in a separate report. Surgicalservices for the trust are run by one management team (thesurgery division) and, as such, are regarded by the trust asone service. For this reason, it is inevitable there is someduplication in the two reports.

Gloucestershire Royal Hospital provides both elective(planned) and emergency surgery. Patients are admitted asboth day-case patients, and to wards as inpatients. Thesurgical specialties include general surgery, trauma andorthopaedics, breast, ear, nose and throat (ENT), oral andmaxillofacial surgery. The operating department atGloucestershire Royal Hospital has 14 theatres. There is a19-bed recovery room within the main theatres. There areseparate facilities for children. Gloucestershire RoyalHospital has six surgical wards, a day surgery unit and asurgical admissions suite.

We visited the following areas: wards 2a, 2b, 3a, and 5b, thesurgical admissions suite, the preadmission clinic, the daysurgery unit and theatres. As part of the trust’s escalationplans, due to winter and the increased pressure on its beds,wards 3b and 5a were being used as medical wards duringour inspection. At other times, these wards would bedesignated for surgical patients.

We spoke with 43 staff, including the theatre matron, headof nursing, ward matrons, ward sisters, consultants,doctors, trainee doctors and nurses. We talked with,healthcare assistants, pharmacy staff and physiotherapists.We spoke with 16 patients. We observed care and looked at13 sets of patients’ records. We reviewed data provided inadvance, during and after the inspection.


In the year April 2015 to March 2016, Gloucester RoyalHospital had 24,779 surgical admissions. Of these, 50%were day-surgery patients, 20% were elective (planned),and 30% were emergency-surgery patients.

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Summary of findingsWe rated this service as requires improvement because:

• Since our inspection in March 2015, the number ofsurgical site infection rates had increased forreplacement hips, knees, and spinal surgery.

• There had been two never events reported in surgerysince our last inspection. These had beeninvestigated and actions taken to prevent thesehappening again.

• Storage for patients’ notes on some wards and unitswas not secure, which meant unauthorised peoplecould have had access to these confidential records.

• Mandatory training for all staff was not meeting thetrust’s target.

• The surgical division was not meeting the trust’starget for staff appraisals.

• Due to pressure for beds and the demand forservices, some patients had to use facilities andpremises that were not always appropriate forinpatients and staff were not aware of how to set upsupport services.

• Elective operations were being cancelled due to thepressure on the beds within the trust, and surgicalwards were being used to accommodate medicalpatients.

• The trust had introduced a new computer systemprior to our inspection that was causing some issuesfor staff resulting in work arounds to prevent anyrisks to patients.

However:

• The service encouraged openness and transparencyfrom staff with incident reporting, and incidents wereviewed as a learning opportunity. Staff felt confidentin raising concerns and reporting incidents.

• The trust had been identified as a ‘mortality outlier’in to relation Reduction of fracture of bone (Upper/Lower limb)’ procedures, which included fracturedhip. However, the actions they had implemented hadmade improvements and these were ongoing at thetime of our inspection. for example, in the 2016 hipfracture audit which had shown an improvement on2015 audit

• Training in safeguarding of adults and children hadmet the trust target for completion.

Are surgery services safe?


We rated safe as requires improvement because:

• Since our last inspection, the number of surgical siteinfection rates for replacement hips and knees andspinal surgery had increased.

• There had been two never events reported in surgerysince our last inspection. These had been investigatedand actions taken to prevent these happening again.

• There was a lack of secure storage for patient’s notes onsome wards and units. This meant unauthorised peoplecould have access to these confidential records.

• Mandatory training for all staff was not meeting thetrust’s target.

• The day surgery unit was being used as an inpatientward but staff were not aware of how to arrangedomestic cover for weekends to provide cleaning anddrinks to patients when staff were busy.

However:

• The service encouraged openness and transparencyabout incident reporting and incidents were viewed as alearning opportunity. Staff felt confident in raisingconcerns and reporting incidents.

• Safeguarding training in adults and children for all staffin the surgical division was meeting the trust’s target forcompletion.

Incidents

• Not all staff were receiving feedback from incidentreporting. Staff told us they were encouraged to reportincidents on the computer system. This lack of feedbackhad been identified at our last inspection. At that time,the divisional surgical management team told us theywere working on how to improve the feedback to stafffollowing incident reporting. However, some senior staffwe spoke with on the wards told us they did providefeedback to their staff following incident reporting andincidents were also discussed at team meetings.Following our inspection the trust told us staff were ableto view the outcome to their incident report using thissystem.

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• All staff employed by the trust (excluding agency staff)were able to report incidents electronically via theintranet.

• We spoke to a band 7 (senior) nurse in theatres whoserole was to spend three-quarters of their time onmanaging risk. They were responsible for ensuring allclinical incidents were investigated thoroughly andlearning was identified and shared with all staff. Thetheatre team aimed to fully investigate all clinicalincidents within 28 days. Each investigation would startwith a scoping meeting, which involved all grades andspecialties of staff to identify where things went wrongand how to ensure that it would not happen again.

• From September to December 2016, there had been anincrease in needle stick injuries (injuries from needles).The theatre risk nurse had produced a quarterly updateand circulated this to all staff to remind them about thesafe use of sharps. Following this, they reported adecrease in the number of needle stick injures inJanuary 2017.

• The trust had reported two never events in surgery inthe year from December 2015 to November 2016. Neverevents are serious patient safety incidents that shouldnot happen if healthcare providers follow nationalguidance on how to prevent them. Each never eventtype has the potential to cause serious patient harm ordeath but neither need have happened for an incidentto be a never event. One incident involved a piece ofequipment, which was left in a patient by mistake, andthe other the insertion of the wrong strength intra ocularlens. Both incidents were attributed to CheltenhamGeneral Hospital, but both were investigated by thetrust and learning shared across the surgery division.Areas identified as needing improvement to reduce therisk of this happening again had action plans, or actionsin the process of being agreed. Staff we spoke with wereaware of both never events and confirmed learning hadbeen shared. One of the never events was discussedamong the staff at one of the multidisciplinaryoperational meetings we attended.

• Actions were taken from near miss events. A near miss isan unplanned event/incident that did not result in injuryto a patient or staff, or damage to equipment orpremises, but had the potential to do so. The incidentwe reviewed related to an implant used in orthopaedicsurgery. During the procedure, the wrong implant wasgiven to the surgeon. However, it was not used as thesurgeon identified it was the incorrect implant prior to

being used. We saw a copy of the action plan detailingall the changes made following this incident. All actionshad been completed. Staff were able to describe andshow us the changes made to practice to avoid thisincident recurring.

• In accordance with the NHS England Serious IncidentFramework 2015, the trust reported 10 serious incidents(SIs) in surgery in the year from December 2015 toNovember 2016. Of these, there were two incidentsreported of ‘surgical/invasive procedure incidentmeeting SI criteria’ and two of ‘healthcare acquiredinfection/infection control incident meeting SI criteria’.The other incidents were all unrelated. Where incidentsof infections were reported, the service had carried outinvestigations and taken actions to reduce the risk of areoccurrence.

• There had been an increase in incidents of surgical siteinfections. Staff within the wards and operating theatreswere aware of this increase and actions had been taken.Actions taken in the operating theatres to reduce thesurgical site infection rates included, for example,changes to dress policy. Staff were no longer permittedto wear scrubs in shops and cafes on the hospital site. Anew testing regime had been introduced. Swabs weretaken of equipment in theatres, including tourniquets,surgeons’ and scrub staff’s hoods used in orthopaedictheatres, to evaluate cleaning regimes. Environmentalrules in orthopaedic operating theatres stated no onewas permitted to enter the theatre once skinpreparation had started unless in a sterile gown andwearing facemasks.

• Each of the surgical specialities reviewed patientmortality and morbidity (M&M). We reviewed sets ofminutes provided for the general surgery division, whichincluded colorectal, upper gastro-intestinal, vascularand urology. In the majority of meetings, they used theClavien-Dindo classification tool. This tool is used to ratesurgical complications for audit, clinical investigationand as a tool for quality improvement. We found therewas variable input, content, and insufficient evidence toshow how agreed actions were deliveringimprovements. In some where presentations were madestaff discussed individual cases and the learningrequired. However, the minutes did not demonstrate ifor how staff were accountable for all actions agreed

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from the reviews or demonstrate improvements fromactions taken. The trust told us following our inspectionthat the governance leads had overall responsibility forensuring actions were met.

Duty of candour

• Staff were able to tell us about the principles of the Dutyof candour regulation. Regulation 20 of the Health andSocial Care Act 2008 (Regulated Activities) Regulations2014 was introduced in November 2014. This Regulationrequires the trust to be open and transparent with apatient when things go wrong in relation to their careand the patient suffers harm or could suffer harm, whichfalls into defined thresholds. Staff told us the regulationswere about being open and transparent with patientsfollowing incidents and apologising to them.

Safety thermometer

• NHS Safety Thermometer information was routinelydisplayed in most ward areas. The NHS SafetyThermometer is a local improvement tool formeasuring, monitoring and analysing patient harms andharm-free care. This tool enabled wards and units tomeasure harm and the proportion of patients that wereharm-free from pressure ulcers, falls with harm, urinarytract infection with catheters, and venousthromboembolism (VTE, or blood clots) during theirworking shifts.

• Data from the Patient Safety Thermometer showed thatthe trust reported 34 pressure ulcers, 20 falls with harmand 25 catheter urinary tract infections in surgery fromNovember 2015 and November 2016.

• The prevalence rate for pressure ulcers had increasedover time however; from October 2016, this had startedto reduce. Ward 5b had the most hospital acquiredpressure ulcers for the Gloucestershire Royal Hospital(GRH) from January 2016 to October 2016, with 19reported. Staff told us this was because they hadmedical outliers and surgical patients with a number ofco morbidities that increased their risk of pressureulcers. Staff were undertaking actions to reduce this riskby reviewing risk assessments and completingintentional or comfort rounds more frequently. The trusttold us after our inspection that for monitoring purposesand good practice all pressure ulcers from grade 2 tograde 4 were reported.

• The prevalence rate for falls with harm was alsoreducing over time, but had seen a sharp rise in

September 2016 and October 2016. November 2016showed the prevalence rate to have fallen to zero. Ward3b had reported the most falls for GRH from January2016 to October 2016 with 73.

• We saw that venous thromboembolism (VTE)assessments had mostly been completed on patientswithin 24 hours of admission. This was to make suretheir risk of developing a blood clot in their leg or lungshad been assessed and actions put in place to reducethe risk.


• Reliable systems were mostly in place to maintainstandards of cleanliness and hygiene to reduce the risksto patients of catching a healthcare associatedinfection. For example, each theatre had an ‘end of theday cleaning checklist’ that needed to be completed.

• Hand hygiene results from January 2016 to October2016 were rated as green but ward 5b was rated as redfor October 2016 and mostly amber for the rest ofperiod. Senior staff on ward 5b told us they were nowrated as green. The trust used a rating system based onred, amber and green. Green being the ward had metthe trust target and red the ward was below the targetset by the trust.

• At our last inspection, we found auditing of MRSAscreening on emergency and elective patients was nottaking place. However, the trust has since carried outaudits. One was undertaken in September 2015, theresults showed that screening from the nose and groinwas over 90%. The data was taken over both hospitalsites on one day and showed for surgery 14 emergencyadmissions patients had not been screened. This wasless than 10% of total admissions that day. The trustwas monitoring and investigating all new cases of MRSAand Clostridium difficile (C diff) and taking actionswhere needed.

• We observed staff in theatres maintaining strict infectioncontrol procedures to prevent the risk of infection forpatients undergoing operations. We observed scrubstaff and surgeons ‘scrubbing’ (this was where staffwashed their hands up to their elbows using specialistsoap and single use scrubbing brushes) and wearingsterile gloves and theatre gowns. All staff in the theatremade sure they did not touch these members of staff sothey were as sterile as possible to prevent the risk ofcross-infection.

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• In theatre skin preparation was used to clean theoperation site to make sure their risk of infection wasminimised. In orthopaedic theatres, there were strictprocedures for all staff to follow once this procedurewas underway. For example, staff were not allowed toenter the theatre unless they were in a sterile gown andwearing a facemask.

• We observed staff in recovery cleaning and checkingequipment at the start of their shift to make sure it wassafe to use and clean. Staff told this was done daily andwe saw records to demonstrate this.

• A care plan bundle was in place for the insertion ofcannula (tube into a vein). This required staff tocomplete on insertion and respond to questions. Forexample, did they undertake hand hygiene prior toinsertion and the use of specialist skin preparation toreduce the chance of an infection. The use of cannulahad to be reviewed daily and staff were required toconsider whether it could be removed as not being usedor if there were signs of infection when it must beremoved.

• We observed staff following the infection control policy.This included being bare below the elbow and ensuringlong hair was tied back.

• Patients who were known to be cross-infection risk wereplaced in rooms with clear labelling to indicate thatappropriate cross-infection procedures should becarried out prior to entering. We saw all staff wearingaprons and washing their hands before entering theroom.

• Clinical waste was managed in line with the trust’spolicy. Single-use items of equipment were disposed ofappropriately, either in clinical waste bins orsharp-instrument containers.

• The day surgery unit was being used as a ward due tothe demands on beds at GRH. This meant inpatientswere cared for on this unit 24 hours a day. However, atweekends staff told us they had no domestic support toassist with cleaning the unit, for example, patient toilets,which was unacceptable. A senior member of trust staffsaid the day unit was able to arrange domestic coverbut the staff on the unit were not aware of how to dothis.


• Gloucestershire Royal Hospital main tower block wasbuilt back in the 1970s and additional wards anddepartments have been added to the surrounding

grounds. The surgical wards, day surgery unit, surgicaladmissions suite and theatres were all located in thetower block at Gloucestershire Royal Hospital, whichhad lifts to assist patients in accessing these areas. Thepre admission clinic was held in a building at the back ofthe hospital. Ward 2a had been upgraded to be used asthe fractured neck of femur and orthopaedic ward. Theward had for example, larger toilets for patientsfollowing surgery and more space to store equipmentneeded.

• Staff on the day surgery unit told us improvements hadbeen made to the environment since our lastinspection. These included a new store cupboard forequipment and a new cupboard for domestics to storetheir cleaning equipment and the waiting/day room hadbeen turned into another bay for patients. However, forinpatients on the day surgery unit there was still nospace for lockers in the female bays. Patients told usthey had to put their belonging on or under their chairnext to their bed. Space was also reduced whencompared to a ward designed for inpatient stays. Stafftold us when they had inpatients on the unit they had toremove the trolleys they normally used for day surgeryto replace with beds.

• Resuscitation equipment on each ward, unit and inrecovery/theatres was checked daily, with records inplace showing completion. However, the day surgeryunit did not have their own defibrillator but shared withan area within the theatre department. Medicationwithin the resuscitation trolleys on the wards, unit andtheatres was stored in tamper-evident containers. This isin line with the guidance issued by the ResuscitationCouncil (UK).

• The hospital had a central sterile services department(CSSD) on site, which decontaminated large volumes ofmedical equipment. The department had beenaccredited internally and externally, and was compliantwith ISO13485 Medical Devices (this is an externalaccreditation to ensure the quality, safety andeffectiveness of medical devices). The departmentaimed for a 24-hour turnaround time, and theatre stafftold us urgent equipment could be turned around inabout 3 hours. Theatre staff spoke extremely positivelyabout this service. Equipment provided by CentralSterile Services Department (CSSD) was also traceable.Staff showed us the process for tracking and tracingsurgical equipment. This included removing stickers

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from the equipment and placing them in patients’notes. This allowed full traceability in the event of anissue being identified with either the patient or theequipment following any procedure.

• CSSD also attended the daily meeting with theatres/recovery, day surgery unit and the surgical admissionssuite. Staff told us any issues with equipment would bediscussed at this meeting with CSSD. In addition, theycould contact them at any time.

• Safety checks were undertaken on anaestheticequipment daily to make sure it was safe to use.

• We saw stickers on electrical and medical equipmentthat stated when it was last serviced and when it wasdue again. This was mostly done in house. These wereall in date.

• Management in theatre told us that there is noequipment replacement programme. However, if apiece of equipment was broken they were able tosubmit a bid for it to be replaced. Staff told us that someof the operating tables were old and that this led todifficulties with maintaining a sterile environment. Thetrust had a system in place for all wards, departmentsand units to request equipment. Meetings took placemonthly, attended by senior trust staff where decisionsfor the purchase of equipment over £5000 were made.For equipment costing over £100,000 a business casewas also required before a decision was made by seniorstaff from the trust

• Staff on ward 2a were provided with equipment toimprove the outcomes for patients following a fracturedneck of femur operation, for example, bladder scanners(to identify if a patient was in retention of urine) andspecialist chairs to enable easy of movement forpatients.

• We were told operating tables had pressure-relievingqualities included to reduce the risk of patientsdeveloping pressure ulcers.

• Equipment was available for bariatric patients toinclude beds, hoists and some of the operating tables.

• On the surgical admission suite, we found the domesticcupboard was unlocked and chemicals covered by theControl of Substances Hazardous to Health (COSHH)Regulations were in an unlocked cupboard. Forexample, chlorine cleaning tablets. This was unsafepractice because patients and visitors could be exposedto these chemicals.

Medicines

• There were arrangements in place for the safemanagement of medicines and these were mostlyfollowed.

• Medicines were stored securely in locked trolleys andcupboards and were kept locked when unattended andsecured when not in use.

• Patients who attended pre admission clinic were givenadvice from the staff about when to stop certainmedication prior to their operation to make sure theydid not interfere with their operation.

• On the other wards we visited, we found fridgetemperatures were recorded daily and no out of datemedication was found, however, on the day surgery unitstaff did not record the refrigerator temperatures daily.This was important to make sure the medicines werestored at the correct temperature to keep them safe touse. During December 2016, the temperature was notrecorded on 22 days and through January 2017; thetemperature had not been recorded on six days. Thetemperature was recorded out of the recommendedrange (2-8°C) on three days in December and January.The staff did not record what actions had been taken.The fridge contained three vials of insulin. As well asbeing stored out of temperature range, we also foundthem to be past their expiry date. This was highlightedto staff that then destroyed the medicines.

• Controlled drugs in the day surgery unit were storedsecurely. Random stock checks were undertaken bystaff, which showed balances were correct as per theregister. Two nurses were involved in checkingcontrolled drugs (CDs) for administration and twosignatures were seen in CD record book. This was thesame on wards 2a, 3a and 5b. CD keys were separatedfrom the main bunch of keys but kept inside one of themedicine cupboards next to the CD cupboard. Thismeant that the CDs could be accessed by the memberof staff that had the main bunch of keys, which may notbe a person, authorised to access controlled drugs. Thiswas not in line with trust policy or good practice.Following a discussion with the ward manger we weretold the CD keys would be remain separated from otherkeys but be in the possession of a registered nurse at alltimes. Nurses did not always sign the received section ofCD order book when receiving delivery of controlleddrugs. This was against the trust policy and goodpractice. This meant that the trust would not easily beable to investigate incidents involving delivery of CDs.

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Staff signed the porter slips who delivered the CDs butthey were only kept for one month. From November2016, we saw CD orders 52, 56, 60, 61, 63, 64, 72 and 73had not been signed as received.

• FP10 prescriptions (these are prescription pads used bydoctors to prescribe medications for patients) werestored securely and their use was tracked on a log sheet.

• The day surgery unit did not receive a clinical pharmacyservice. Staff told us they thought this was a clinical riskas patients frequently stayed for more than one day,and they found it difficult to resolve all the issues withthe medicines. This was evidenced on the threeprescription charts seen where no medicinereconciliation had been completed. This was not on thesurgery risk register.

• We reviewed three prescription charts and found all hadallergies recorded, two out of three patients had theirVTE assessment completed, all patients details werecorrect ( name, date of birth etc.), all prescriptions weresigned and dated and the length of course andindication for use was recorded for antibioticprescriptions. The standard set in the trust policy was‘zero blank boxes’ within medicines administrationcharts. These were the boxes completed to show thedrug had been administered or reasons why it had not.We found one blank box for fragmin 5000 units on aprescription chart where there was no signed evidence ithad been administered.

• In recovery, we saw that oxygen requirements wererecorded in the anaesthetic chart by the anaesthetistand all staff knew where to find this. If a patient requiredoxygen for transfer to the ward and post operation thiswas then prescribed on their prescription chart.

• Staff on the wards and theatres/recovery told us that allmedication errors were reported via their incidentreporting system so they could be investigated andactions taken to reduce them from happening again.The nursing metrics for GRH showed the number ofmedication errors from January 2016 to October 2016.Ward 5b had the most with 14. Ward 5a had two in thesame period and ward 2b had reported no medicationerrors.

Records

• Patient records were mostly stored securely and were inline with the patient’s nursing needs and medicalreviews. At the last inspection, we found patient noteswere not being stored securely on wards 2b and 3b. New

lockable trolleys had been purchased for each ward.However, at this inspection, we found ward 3a and 5bdid not have secure storage facilities. On 5b in thesurgical admissions unit, they were stored on a trolley inthe small office area, which gave potential forunauthorised access.

• On ward 5b we found one of the medical students hadwritten up the notes from the ward round and hadslipped the piece of paper directly into the patient’sfolder without securing it. This was reported to seniorstaff, as this could have easily been lost. It containedvery little detail to identify the patient if it had got lost,reducing the likelihood of reconciliation.

• Nursing records were mostly held at the end of patients’beds. However, on ward 3a these were stored in foldersin the bays.

• Care pathways were in place for surgery patients. Theseincluded separate pathways for patients undergoing daysurgery. Both nursing and medical were included inthese. Records were comprehensive and includeddetails of the patient’s admission, risk assessments,treatment plans, and records of therapies provided. Wesaw preoperative records, including completedpreoperative assessment forms. Medical recordsaccompanied patients to and from theatre.

• All consent forms we viewed were completed in full,signed, and dated by the patient and the consultant. Allrisks associated with the operation were alsodocumented.

• Core risk assessments and care plans were in place forpatients with mental health illnesses, for example,disorientation and memory loss, alcohol withdrawalmanagement plan and patients at risk of self-harm. Onthe wards we visited and the patients records wereviewed none of the patients required these plans,however staff were aware of where they could accessthese.

Safeguarding

• Arrangements were in place to safeguard adults andchildren from abuse and staff understood theirresponsibilities to report allegations. Staff told us theyknew how to make a safeguarding referral and wereaware of who were the safeguarding leads for the trustfor adults and children.

• Information about safeguarding was displayed on anumber of noticeboards across the surgery wards andunits.

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• The surgical division had exceeded the trust target of90% completion of all four areas of training. These were;safeguarding awareness, safeguarding adult’s level 2,safeguarding children awareness and safeguardingchildren level 2. This was for medical/dental staff andnursing staff.

• The surgical divisional management team told us thatpatients over the age of 70 with fractured hips couldhave access to an orthogeriatrian.

Mandatory training

• Staff were mostly up to date with training in safepractice, processes and systems. The trusts mandatorytraining for all staff included, basic adult resuscitation,blood transfusion, code of conduct, conflict resolution,equality and diversity, fire, infection control, informationgovernance, manual handling theory and practical,medicines management and safety awareness.

• The surgical division across both sites had met thetrusts target of 90% for three of the 12 modules for themedical and dental staff group, equality and diversity,information governance and safety awareness. Theremaining nine modules were just below the targethaving completion rates between 83.1% and 89.9%.

• The surgical division across both sites had met thetrusts target of 90% for nine of the modules for thenursing staff group. The remaining three modules (basicadult resuscitation, conflict resolution and manualhandling practical) were just below the target havingcompletion rates between 83.8% and 86.6%.

• Staff in theatres told us they had time put aside toundertake mandatory training and this was called auditdays. A half-day audit period was due to take place onthe last day of our inspection. Practical training tookplace during this time, for example, moving andhandling pertinent to theatres. Staff also had mandatorytraining to complete on the trusts e-learning system.

• Staff told us they had received training on sepsisidentification and management.


• Risks to patients who were undergoing surgicaloperations/procedures had been assessed and theirsafety monitored and maintained. Patients for someelective surgery attended a preoperative assessmentclinic where all required tests were undertaken, forexample, MRSA screening and blood tests. If required,patients could be reviewed by an anaesthetist. When

additional tests were ordered, the pre-operativeassessment clinic had a process in place to follow theseup and inform the surgeon or anaesthetist if any issueswere identified. Some patients had telephoneassessments if they met a certain criteria and staff toldus they sent the MRSA testing kit and instructions totheir address. During the pre-admission clinics somepatients were reviewed by clinical nurse specialists, forexample, stoma nurses could help prepare patients forchanges to their life style following surgery.

• We observed the use of the World Health Organisation(WHO) surgical safety checklist in all theatres. TheNational Patient Safety Agency recommended that thisprocess be used for every patient undergoing anysurgical procedure. It involved a number of safetychecks designed to ensure that staff avoided errors.

• We saw the results of the WHO audit undertaken intheatres dated June 2016. This had some areas rated asgreen where they met the target and some areas wererated as amber or red. The audit had identified areaswhere clinical engagement was still an issue resulting inthem not meeting their target of 100%. A new processhad been started in December 2016 but at the time ofour inspection, this had not been re-audited.

• We observed a surgical safety operating list briefing,which included what operations were taking place onthat list and the staffing numbers. We also saw the WHOchecklist being completed which included sign in timeand sign out time.

• We spoke with the lead coordinator for the emergencytheatre. They met with the on call lead anaesthetist andconsultant surgeons who had patients for the list eachmorning. The order of the list was agreed based onclinical assessment of each patient.

• The trust used the National Early Warning Score (NEWS).This tool is used to aid recognition of deterioratingpatients, based on scored observations includingtemperature, pulse, blood pressure and respiratory rate.A high total score activated an escalation pathwayoutlining actions required for timely review, to ensureappropriate interventions for patients; these wereclearly documented on the form. Staff explained howthey used this tool and when they would contactdoctors for additional support. The trust audited theirNEWS scores monthly. The figures sent to us for October

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2016 showed that they were at 100% completed as pertheir policy for all surgery wards. The frequency ofobservations undertaken in line with NEWS procedureaudit all showed each surgery ward was at 100%.

• A pathway was in place to provide guidance for staff tofollow and when to obtain medical advice.

• Staff on the wards told us that if a patient was assessedor known to have a mental illness they referred them tothe mental health teams, for example, crisis team,alcohol liaison and for older people. However, not allstaff felt they were quick to respond. For patients onward 2a (fractured neck of femur ward andorthopaedics) they had access to mental healthqualified nurse in a senior role. The trust had devisedcore risk assessments and care plans for a number ofmental health illnesses as mentioned under the recordsheading.

Nursing staffing

• ▪ Staffing levels and skill mix were planned andreviewed but there were vacancies for nursing staff insome of the surgery wards and theatres. The trustwas working hard to address the vacancies. Forexample, they had several projects in place tosupport recruitment. These included supportingoverseas nurses to achieve the required Englishlanguage qualification, engagement in roledevelopment and working in a strategic partnershipwith the local university to ‘grow their own’ nurses.

▪ The surgical division used ‘The Keith Hurst’ tool,often referred to as the Safer Nursing Care Tool,which helps determine safe nurse staffing for acutewards based on patients’ level of sickness anddependency. This tool has the added benefit ofbenchmarking staffing as it included data on skillmix, levels of clinical dependency, clinical specialityand quality markers as part of the overall staffingassessment. The trust told us this tool had acuitymeasurements included and they did not undertakeany other acuity reviews.

▪ At August 2016, all six surgery wards and day surgeryunit were below establishment. Overall there was adeficit of 20.5 Whole Time Equivalent (WTE).The daysurgery unit had the largest deficit of 7.17 WTE. Thetrust sent us figures following the inspection of theirsafer staffing summary. For example, ward 2a fromSeptember 2016 to December 2016 showed their

actual safer staffing qualified nurses figures for dayshifts was higher than their planned figures exceptfor December 2016 due to some changes takingplace on the ward. This was also the same for carestaff. For ward 3a for the safer staffing figures fromSeptember 2016 to December 2016 for day shifts alsoshowed that the planned number of qualified staffon duty was above the actual staffing figures. Thiswas also the same for care staff. The only change wasin December 2016 when they had slightly less trainedand care staff on duty compared to their plannednumbers. We were not sent the safer staffing figuresfor the day surgery unit as they had high usage ofbank/agency staff between December 2015 toNovember 2016 ranged from 27.3% to 48.1% so wecould not compare planned verses actual staffinglevels. Staff told us bank and agency staff were usedat times to cover these vacancies.

• Theatre staffing levels were based on the Association forPerioperative Practices (AfPP) guidelines and on thenumber of theatre sessions per day. Staff told us thatthere were higher levels of vacancies within theorthopaedic teams, which they felt was due to theworkload. Three agency nurses had been working withthem for a long period, and permanent staff felt theyworked well as part of the team. Theatre managers toldus that they were in the middle of a major push onrecruitment, including offering staff to attend anoperating department practitioner’s course, and holdingopen days.

• Sickness levels within theatres were low at 3.0%, andmanagers told us that this was managed well withsupport from occupational health when required,although there was a backlog.

• In November 2016, the trust reported a vacancy rate of16.9% for surgery trust wide, though for GloucestershireRoyal it was above at this rate at 18.2%.

• Turnover rates at November 2016 trust wide for surgerywas reported as to be a rate of 12.2%. ForGloucestershire Royal this was 13.3%, which was worsethan trust figure.

• Sickness rates at November 2016 for surgery trust widewas reported at a rate of 4.6% with GloucestershireRoyal at 4.7% worse than the trust figure.

• From December 2015 to November 2016, the trustreported an average monthly bank and agency staff

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usage of 9% across the surgical division. ForGloucestershire Royal Hospital, this was below at 8%.Where possible wards, departments and theatres usedthe same staff for continuity of care for patients.

• Staff on ward 5a told us they felt de-skilled and had abusier workload due to the high numbers of medicaloutlying patients on the ward. Some staff told us theywere leaving because of this. However due to thepressure on beds within the hospital and increasedworkload, they were able to have an extra health careassistant on the day shifts.

Surgical staffing

• From 1 August 2016 to the 31 August 2016, theproportion of consultant staff reported to be working atthe trust was higher than the England average and theproportion of junior doctors (foundation year 1-2) staffwas lower. The surgical division management told usthey had a shortage of junior doctors, which had animpact on their services. They had appointed AdvancedNurse Practitioners (ANP) to support junior doctors inundertaking some of their roles so the junior doctorscould spend more of their time diagnosing patients. Useof locum doctors in the surgery division was reported bythe trust to be average compared to other trusts.Between December 2015 and November 2016, the trustreported an average monthly bank and locum staffusage of 10%.

• We spoke to an anaesthetist who told us they had 50senior anaesthetic staff across the trust. These includedstaff grades (who are classed as middle grade doctorsbut not yet as senior as a registrar or consultant). Thirtyof these worked at Gloucester Royal. Junior doctors intraining were extra to these numbers. There was an oncall rota for covering surgery. Anaesthetic cover for thecritical care unit was managed separately.

• All surgery specialities had on call consultants and ateam of junior doctors, For example, trauma andorthopaedics had a consultant on call from the hours of8am to 8pm and after this time; one consultant coveredboth hospital locations. A trauma meeting took placeevery morning, which was attended by a proportion ofthe orthopaedic team, trauma coordinator, theatre andanaesthetic staff. The orthogeriatian consultants did notattend these meetings. This meeting was used todiscuss all patients who had been admitted. At

weekends, we were told that all new hip fracturepatients over the age of 70 years were seen by anorthogeriatian and those that were one-day postoperation.

• Nursing staff we met said they felt well supported by thesurgery teams. Consultants and doctors carried outappropriate ward rounds mostly at set times, althoughon the day surgery unit they reported a variable practiceat times. Although, some of the wards did not havedoctors based there, they usually came quickly whenrequested and did spend most of their time on thewards. When we visited the hospital on both theannounced and unannounced visits, we observeddoctors reviewing patients and coming onto wardswhen requested by nursing staff. Some of the wards andday surgery unit had reported difficulties at times ingetting medical outlying patients reviewed by medicalteams.


• Arrangements were in place to respond to emergenciesand major incidents. The trust had a major incidentplan, which was available to staff on the intranet.

• Staff in theatres told us one of the actions they had totake if a major incident took place was to stop allelective operations.

• If they suffered an electrical power cut they hadgenerators in place to be able to complete operationssafely until the power was restored.

• During our inspection, the trust had implemented theirwinter pressure plan, which included changing twosurgical wards to medical wards to cope with anincreased number of medical admissions. This hadresulted in a number of cancelled elective operations.

Are surgery services effective?

Good –––

We rated effective as good because:

• The trust had been identified as a ‘mortality outlier’ in torelation reduction of fracture of bone (Upper/Lowerlimb)’ procedures, which included fractured hip.However, the actions had implemented had madeimprovements and these were ongoing at the time ofour inspection.

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• Staff were using national guidance to improve theoutcomes for patients.

• Patients were having their pain levels assessedappropriately and overall patients were pain free.

• There was good multidisciplinary working across allstaff groups to make sure patients care wascoordinated.

However:

• The trust had introduced a new computer system priorto our inspection. This was causing issues for staffresulting in 'work around' processes to prevent any risksto patients. The trust was working to address these.

• Staff appraisals were not meeting the trust targets.• Theatre utilisation figures were low however; the trust

was looking at ways of improving this.


• Staff on the ward, units and in theatres had access topolicies and procedures that were based on nationalrecognised guidance, for example National Institute forHealth and Care Excellence (NICE) guidance.

• Standard Operating procedures in theatre were basedon national guidance, for example, those set by theAssociation for Perioperative Practice (AfPP). We wereshown several of these as evidence.

• Staff in theatres told us they had some input intopolicies and procedures that were developed by theeducation team specifically for them.

• We observed staff in theatres and recovery meetingNational Institute for Health and Care Excellent (NICE)guidance, for example, Hypothermia: prevention andmanagement in adults having surgery. In order tomaintain a patient’s body temperature above 36degrees centigrade, patient warming devises were seenbeing used and staff were seen using devices to warmintravenous fluids. Practice was also seen to follow NICEguidance CG74 surgical site infections: prevention andtreatment.

• We saw in the patient records we reviewed that allpatients had a venous thromboembolism (VTE)assessment completed on admission as recommendedin the NICE guidance QS3. This also recommendspatients be reviewed within 24 hours. In most but not allthe patient records we reviewed this had taken place.

• The colorectal surgeons followed the EnhancedRecovery programme for some patients who met setcriteria. These pathways provided evidence-basedprotocols to ensure patient recovery was maximised.

• Staff in the pre-admission clinic told us they discussedwith patients about how to make sure they were fit fortheir operation. For example, advice was given aboutsmoking and alcohol intake.

Pain relief

• Patients had their pain assessed and managed. Thetrust had a consultant led dedicated pain team,supported by senior nurses. Staff in recovery and on thewards told us the pain team were aware of patients whowould require epidurals and patient-controlledanalgesia machines prior to their surgery. The teamprovided support and advice to ward staff and patientsregarding pain control and for patients with epiduralsand patient-controlled analgesia. Out of hours and atweekends an anaesthetist provided this support.

• We saw pain scores recorded on the patients NEWSchart and staff told us they monitored these andprovided patients with pain relief as and when required.We observed this taking place in recovery and followingadministration of analgesia staff then re checked theirpain score.

• A protocol was in place for pain management as part ofthe care pathway for day case patients, which includedtypes of analgesia and dose range.

• The majority of patients we spoke with about their paintold us it was well controlled and they would ask thenurses if they needed more pain relief. However, on theday surgery unit three patients told us they had to wait along time to receive pain relief after they had requestedit.

• A specialist pain score tool was used for patients withcommunication difficulties. For example, it had anumber of faces showing facial expressions thatpatients were asked to pick to help identify their painlevel.


• Patients had their nutrition and hydration needsassessed and monitored. The Malnutrition UniversalScreening Tool (MUST) was used to monitor patientswho were at risk of malnutrition. The tool (an accreditedscreening tool) screens patients from risks ofmalnutrition but also for obesity. Where patients were

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identified, as at risk, nutritional care plans weredeveloped to encourage intake, a food chart wascommenced, and there was involvement from adietician. We saw in one patient record a referral to adietician based on their clinical need and MUST score.

• Staff at the preadmission clinic told us there wasguidance for patients about when they should be ‘nil bymouth’ from, depending on their operation time. It alsomentioned patients should not have sweets or chewinggum. Patients were able to have water up to two hoursprior to surgery. Information about fasting was alsoincluded on the trust’s website.

• Some patients who were undergoing colorectal surgerywere prescribed pre-operative drinks. These drinks wereused to improve the patients’ nutrition prior to theiroperation and to encourage a quicker recovery.

• In recovery, we saw patients were assessed, monitoredfor nausea, and vomiting. On the medicationadministration records we saw anti-emetics wereprescribed for patients. We spoke with anaesthetistswho told us most patients were given anti-emeticmedication whilst undergoing their operations toprevent any nausea and vomiting post operation. Theysaid this was part of their protocol. We spoke with sixpatients whilst in recovery and all said they had nonausea or vomiting.

Patient outcomes

• Information about the outcomes of patients care andtreatment were routinely collected and monitored. Inthe 2015 bowel cancer audit, overall performance wasbetter than the England average. However, 67% of trustpatients undergoing a major resection had apost-operative length of stay greater than five days. Thiswas worse than the national average but animprovement on the 2014 figure of 51%. Mortality rateswere better or within the expected limits.

• In the 2016 Oesophago-Gastric Cancer National Audit(OGCNCA), the trust was within the expected limitscompared to other trusts.

• In the 2016 Hip Fracture Audit, the risk-adjusted 30-daymortality rate was 10.4% which is worse than expectedbut shows improvement versus the 2015 figure of 12.5%.The proportion of patients having surgery on the day ofor day after admission was 73.2%, which does not meetthe national standard of 85% and is worse than the 2015figure of 80.6%. The perioperative surgical assessmentrate was 96.4%, which does not meet the national

standard of 100% but shows improvement versus the2015 figure of 90.9%. The proportion of patients notdeveloping pressure ulcers was 98.4%, which falls in themiddle 50% of trusts. The 2015 figure was 98.1%. Thelength of stay was 10.4 days, which falls in the bottom25% of trusts but has decreased versus the 2015 figureof 12.5 days.

• In the 2016 National Emergency Laparotomy Audit(NELA), Gloucestershire Royal achieved green (above80%) ratings for the proportion of cases with access totheatres within clinically appropriate time frames andthe proportion of highest-risk cases admitted to criticalcare post-operatively. They were rated amber (50-69%)for the number of cases with pre-operativedocumentation of risk of death and for the proportion ofhigh-risk cases with a consultant surgeon andanaesthetist present in the theatre. The risk-adjusted30-day mortality rate was within expectations.

• The hospital had mixed performance for PatientReported Outcome Measures (PROMs) between April2015 and March 2016. Patients reported their outcomefollowing surgery for groin hernias, hip replacements,knee replacements, and varicose veins. The groin herniaand knee replacement indicators showed that overallthe trusts performance was similar to the Englandaverage. The hip replacement and varicose veinindicators showed that fewer patients’ reported animprovement in health after treatment and morepatients’ reported a worsening in health after treatment,compared to the England average.

• There had been an increase in surgical site infections insome procedures. At our last inspection, the surgical siteinfection (SSI) rate for Gloucestershire Royal Hospitalfrom October 2014 to December 2014 for total kneereplacement surgery was 0.1% lower (better) than thefive year England national average of 2.2%. The rate forhip replacements was 0.9% lower than the five yearEngland national average of 1.3%. However, since thenthe trust had experienced a marked increase in SSI atboth Gloucestershire Royal and Cheltenham hospitals.The trust was identified by Public Health England as‘high outliers’ in ‘inpatient/readmission’ SSI at bothhospitals for the period of July 2015 to August 2016. Thiswas due to a particular rise identified in July toSeptember 2015. The trust told us their current rate formost up to date quarter does not place them as outlierswith Public Health England as improvements have beenseen.

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• Latest figures from the data sent to us by the trustshowed for the trust as a whole for SSI in hipreplacement surgery between July 2016 and September2016, was 4% GRH 4%, CGH0%). This was higher (worse)than the national average of 1.1%. This figurerepresented five cases.

• The latest figures from the data sent to us by the trustshowed for the trust as a whole for SSI for kneereplacement surgery for the same period was 7.6% (GRH3.4%, CGH 0.8%). This was higher (worse) than thenational average of 1.5%. This figure represents sevencases.

• For spinal surgery at Gloucestershire Royal only for thesame period, the overall SSI rate was 2.7%. This washigher (worse) than the national average of 1.8%. Thisfigure represents two cases.

• The latest data we had for reduction of long bone fromJanuary 2016 to March 2016 was 2.4% (GRH 2.1%, CGH2.9%) which is higher (worse) than the national averageof 1.5%. This figure represents four cases.

• For fractured neck of femur for the period January 2016to April 2016, the rate was 0.5% (GRH 0.8%, CGH 0%)which is lower (better) than the national average of1.5%. This figure represents one case.

• The surgical division management team told us theyhad investigated the increase in surgical site infectionrates but were not able to identify a specific cause. Theywere using ‘Getting it right first time’ (GIRFT) which hadbeen adopted by the Department of Health. Thisguidance looks at solutions to reducing surgical siteinfection rates. An action plan had been devised to lookat ways of reducing the risks to patients.

• The surgical admissions suite was due to take part in anaudit the week after our inspection to look at improvingpatients’ hydration levels pre operation to help theirpost operation recovery. This was to take place acrossboth hospitals.

• The standardised risk of readmission for elective surgerywas better than the England average for all specialitiesexcept for ear, nose and throat (ENT) which was worsethan England average. For non-elective surgery, allspecialities were better than England average againexcept for ENT.

• The formation of a Theatre Transformation Board was inprogress to look at ways of improving theatre utilisation

and session efficiency due to low usage figures Forexample between June 2016 to August 2016 theseranged across all theatres from 52% to 82%. Cancelledoperations would have also had an impact on this.

• The trust had been identified as being a mortality outlierfor Reduction of fracture of long bone (Upper/Lowerlimb)’ procedures. The trust had reviewed all deathsbetween 1 February 2015 and 31 January 2016 to findout why there was an increase in mortality betweenthese dates. Eighteen of the 26 of these patients whodied were identified as hip fracture patients. This reviewidentified areas of good practice and areas whereimprovement was needed. The findings wereincorporated into an action plan that also covered theoutlier for fractured neck of femur. At our last inspection,the surgical divisional management team told us thetrust had commissioned an independent review by theRoyal College of Surgeons, as their own investigationshad not been able to identify the reason for the increasein mortality rates. This review took place in April 2015.Findings were incorporated into an action plan whichwe followed up. Changes to the location of the ward hadbeen made and patients were now on ward 2a.Environmental changes had been made to aid recovery,for example, larger toilet areas and space for storingequipment so it was not in the way when patients weremobilising. We spoke with the advanced nursepractitioner who was appointed to support juniordoctors. A practice educator was also in place on thisward focussing on the deteriorating patient. An updatedhip fracture admission proforma was also implemented.This contained a management protocol for all staff tofollow and included the emergency department as wellas surgery wards. It included for example, painmanagement, nutrition, pressure ulcers and mentionedthe possibilities of post operation delirium. A furtherreview by The British Orthopaedic Association had takenplace in November 2016 as the trust had agreed to takepart in the Health Foundation sponsored (HIP QIP)quality improvement programme. This project involvesreplicating the learning from other trusts to improveoutcomes for patients from trusts who were strugglingto provide safe, high quality hip fracture care to patients.The sites were selected based on poor outcomes in theNational Hip Fracture Database annual report. Theproject aims to help these trusts to provide hip fracturecare of the highest quality, ensure recent evidence andnational standards are systematically implemented, and

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provide improved patient experience. The report was indraft form during our inspection and therefore we werenot able to use information from it. However, it focusedon their achievements and areas for improvement. Thetrust told us an internal audit of their mortality rate hadshown they were back within the standard range.

Competent staff

• Staff had access to training to improve their skills andknowledge. Staff in theatres told us they hadcompetency assessments in place they had to meet.These varied depending on their role and grade. Themajority of staff were evaluated for their competence. Inrecovery, for example, staff followed the guidelines ofthe Royal College of Anaesthetists. Standard sets ofcompetencies for nurses and operating departmentpractitioners (ODPs) were in place to enable staff todemonstrate competency to the Association forPerioperative Practices and to enhance skills andknowledge within operating departments, associatedareas and sterile services departments.

• The surgical division was below the trust target of 90%of appraisals completed for all staff groups, allied healthcare professionals, health care assistants, medical anddental, nursing and others to include clerical staff. Theseranged from 67% to 83%. New staff were required towork a period of supernumerary time on wards, unitsand theatres/recovery. There was a set period of time,which could be extended based on the needs of themember of staff. They were also required to completecompetency tests to assess their skill base.

• The wards, units and theatres/recovery had link nursesfor specific areas, for example pressure ulcers anddementia. These staff could then share their additionalknowledge with other staff.

• Medical staff were evaluated for their competence.Medical staff took part in the revalidation programme.This is a General Medical Council requirement for all UKlicenced doctors to demonstrate they are up to date andfit to practise. This is tested by doctors participating in arobust annual appraisal leading to revalidation by theGMC every five years.Appraisals of medical staff werecarried out each year and they were below the trusttarget of 90% at 75%

• Staff on the wards and theatres told us they did not havetraining specifically about mental illness but most hadcompleted the dementia and learning disabilityawareness e- learning training. Figures provided by the

trust showed that 72% of nurses had completeddementia awareness level one; 86% had completedlevel two dementia awareness training and 92% inlearning disability. The trust told us following ourinspection that health care assistants were able toaccess training on how to care for patients who selfharm and on how to provide one to one care.

• Senior staff told us there was a process in place foridentifying and managing poor or variable staffperformance. They said staff were supported to improvetheir practice and offered additional training to meettheir needs.


• All necessary staff, including those in different teamsand services, were involved in the assessing, planningand delivery of patients care and treatment. In theatres,they had daily teams meetings for each theatre and thenthese fed into the daily multidisciplinary operationalmeetings, which also took place each morning.Representatives included a member of staff from eachtheatre, theatre management, staff from the day unit,the surgical admissions suite and Central Sterile StoresDepartment (they were responsible for supplying andcleaning of theatre kits). Staff were able to discuss anyissues they might have that day with for example,staffing, equipment etc. so others were aware andresolutions could be found.

• We observed multidisciplinary teamwork in theatre inrelation to the use of the World Health Organisationsurgical safety checklist. Each member of the team hada recognised role and took part as required.

• We observed physiotherapists and occupationaltherapists working with patients on the wards and daysurgery unit and they liaised with the nursing staff andmedical teams who were involved in the patients care.

• We observed a daily board round which took place onthe ward 2a and this included nursing staff andtherapists where each patients planned care wasdiscussed. These rounds also took place on the othersurgery wards.

• To assist the staff on the surgery wards a dischargeliaison team was available for patients who hadcomplex needs and required detailed planning beforethey could be discharged. They provided support for theward staff, for example, they would liaise with externalprofessionals, including care homes. We observed thisteam on the surgery wards during our inspection.

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Seven-day services

• The hospital provided emergency surgery servicesaround the clock. There was a designated emergencytheatre and team on site 24 hours a day with surgeonsand support staff on call. This theatre was available forany surgical speciality. There was system in place forbooking patients onto the emergency list that wasoverseen by a senior member of staff in charge of thetheatre.

• The hospital sterilisation and decontamination services(CSSD) also operated seven days a week to make sureall equipment needed was available.

• Some surgical patients were reviewed daily by aconsultant, including weekends. However, consultantsdid not routinely review elective orthopaedic patients atweekends.

• There was no out-of-hours cover for occupationaltherapy (OT). However, on the elective orthopaedic wardthere was OT support on a Saturday morning as part ofthe care pathway.

• For physiotherapists, criteria were in place for weekendvisits. This included for elective orthopaedic wardpatients, new patients and patients needing to bedischarged. A physiotherapist was also on call at nights.

• The dedicated pain team did not work weekends. Theon-call anaesthetist provided any support required.

• Dieticians did not provide an out-of-hours, on-call orweekend service. As a result, patients admitted over theweekend in need of dietetic referral had to wait untilMonday to be seen

• Staff told us they had access to an out-of-hourspharmacy and imaging. The pharmacy was open atweekends for set hours and a pharmacist was availableon call outside of these times.

• We saw the out-of-hours rota for surgery for eachspecialty. It included junior doctors, registrars andconsultants. A consultant was on call at all times foreach of the specialties, alongside a registrar and juniordoctors.


• Information needed to deliver effective care andtreatment was not always available for relevant staff in atimely and accessible way. Staff we spoke to at all levelstold us of their frustration with the new online theatresystem introduce as part of the upgrade to the patientadministration system prior to our inspection. We were

shown examples where the procedures that patientswere due to have in theatre was not identified in theinformation provide at the start of the day to theatrestaff. Administrative staff were entering this informationinto the ‘comments box’ and staff raised concerns thatthis was a risk as there was an increased risk of wrongsite surgery. The expected length of time for theprocedure was arbitrary. Theatre lists no longer showedwho the attending anaesthetist would be, and thesurgeons name was not always accurate. Staff also toldus that they were concerned that there was a risk thatpatients could be missed as the reporting wasinaccurate. For example, one patient had arrived in thesurgical admissions unit but was not expected by staff.Theatre managers told us of concerns they had thatpatients cancelled from theatre lists could be lost fromthe system. They also told us that theatre schedulingstaff were spending on average an extra 30 hours permonth to produce theatre lists. Staff also describedbeing unable to get usable reports from the system,such as efficiency target data. The trust was workinghard to address the issues identified by staff.

• When patients were transferred between wards,departments and units all their nursing and medicalrecords were transferred with them. Staff also provideda verbal handover as well as the written records.

• We observed a handover between a recovery nurse anda ward nurse. Important information was given to theward nurse about the patient and documentation wascompleted.

• When a patient was discharged to other services, forexample, into the care of community nurses, practicenurses and care homes they completed a letter thatincluded details of the patient’s needs and what supportand treatment was needed.

• We spoke with two junior doctors who told us theycompleted GP summaries to be sent out. They wereunsure what happened to the summary in the computersystem once they had completed their section. Duringour unannounced inspection one ward told us theywere having problems with the new computer systemand sending out of GP summaries, (they were sentelectronically) however they were able to rectify this. Onthe day surgery unit, not all staff having the correctaccess to the new computer system As a result, they also

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experienced issues with sending out GP summaries.This posed a risk to patients as a delay in GP’s receivingthis information could have an impact on theircontinued care.

• However, there was good access to intranet-basedguidance, policies and protocols. The trust intranet wasopen and available to all authorised staff.


• Staff understood the relevant consent and decisionmaking requirements of legislation and guidance.Patients we met said they had been asked to provideconsent both verbally and by signing a consent form.The nurses in the clinic or nurse specialists told patientswho attended the pre admission clinic about theoperation. On the day of their operation, the consultantand anaesthetist saw patients prior to their operation.Patients told us they had been told all the risks andbenefits of the operation/procedure and were able todiscuss what impact the procedure would have on theirwellbeing.

• Staff told us they had four different types of consentform, including one for children and one for patientswho lacked capacity to consent to their procedure/operation. The consent forms we saw were appropriateforms according to the patients’ needs were completedin full and had been signed by the doctor and patient.Forms included details about the procedure/operationand any possible risks or side effects.

• Staff on the wards understood about best interestdecisions and where these needed to be recorded. Atthe last inspection, we found a best interest decisionhad not been recorded in the patients’ notes. We did notwitness this at this inspection as all of the patients'notes we examined referred to patients who had thecapacity to make their own decisions.

• Staff said they knew how to make a Deprivation ofLiberty (DOLs) application if it was required and theycould access support from a social worker if requiredwhen completing DOLS applications. There were nopatients on the surgery wards who were under a DOL’sduring our inspection.

• The trust reported that as of October 2016, MentalCapacity Act (MCA) training had been completed by

90.4% of all staff in within surgery. Deprivation of Libertytraining had been completed by 90.3% of all staff. Thecompletion rate for both modules met the trust target of90%.

Are surgery services responsive?


We rated responsive as requires improvement because:

• Due to pressure for beds and the demand on services,some patients had to use facilities and premises thatwere not always appropriate for inpatients.

• Elective operations were being cancelled due to thepressure on the beds within the trust and medicalpatients were being cared for on surgical wards to meetthe demand.

• Not all patients had their operations re-booked withinthe 28-day timescale.

• Six patients had been waiting over 52 weeks fortreatment, which is not acceptable.

• Some surgery wards had problems having medicalpatients reviewed by medical doctors and therefore thisaffected their discharge.

However:

• The trust’s referral to treatment time (RTT) for admittedpathways for surgical services between January 2016and November 2016 has been about the same as theEngland overall performance.

• The average length of stay was for non-elective patientswas better than the England average.

• At our last inspection, the day surgery unit was havingdifficulties accessing doctors and other health carespecialists for their inpatients. At this inspection, wewere told this had improved.

• Staff in theatres and recovery had guidance in place tohelp reduce the anxiety of patients living with dementiawhen they using their services.


• Services were planned and delivered to meet the needsof local people and the demands of the service. Thesurgical division management team told us they hadplans to review how surgery services functioned acrossboth hospital sites. A number of surgical specialities had

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been reconfigured to one of the hospitals, for example,ear, nose and throat surgery was based at GloucesterRoyal Hospital and ophthalmology was carried out atCheltenham General Hospital where vascular serviceswere also situated.

• As part of service planning due to winter pressures andthe increase demand on beds in the trust two surgicalwards were being used for medical patients. This had animpact on the number of elective operations that couldbe undertaken. The day surgery unit was being openedboth day and night and at times had medical inpatientswhen the demand for beds within the hospital was high.Despite this, the number of surgical admissions trustwide had increased by over 1000 patients since our lastinspection.

• An emergency surgical ambulatory care unit was beingdeveloped on ward 5b, with the overall aim being totake direct surgical admissions rather than patientshaving to go through the emergency Whilst the unit wasopen it wasn’t fully operating as a surgical ambulatorycare unit as they also had medical outlier patients. Planswere also in place to improve the elective surgerypathway with the aim to improve patients experienceand outcomes. This included, looking at staggeredadmissions times so patients are not waiting for longperiods and a one-stop clinic and pre operationassessment. This work was also ongoing during ourinspection and changes to practice had yet to beimplemented.

Access and flow

• Between January 2016 and November 2016, the trust’sreferral to treatment time (RTT) for admitted pathwaysfor surgical services has been about the same as theEngland overall performance. The latest figures forNovember 2016 showed 72% of this group of patientswere treated within 18 weeks versus the Englandaverage of 71%.Ophthalmology, ENT and generalsurgery were above (better than) the England averagefor admitted referral to treatment times whilst urologyand oral surgery were below (worse than) the Englandaverage.

• There were 1,172 cancelled operations for the periodOctober 2015 to September 2016, of which 7.8% (91)were not re-booked for surgery within 28 days. Alast-minute cancellation is a cancellation fornon-clinical reasons on the day the patient was due toarrive, after they have arrived in hospital or on the day of

their operation. If a patient has not been treated within28 days of a last-minute cancellation they are recordedas having breached the standard. As a result, the patientshould be offered treatment at the time and hospital oftheir choice. Cancelled operations as a percentage ofelective admissions for the period October 2014 toSeptember 2016 at the trust were greater (worse) thanthe England average. The number of operations wherepatients were cancelled more than once betweenJanuary 2016 and November 2016 was 778, withFebruary 2016 being the most at 108.

• The trust told us they had seven patients who hadwaited over 52 weeks for treatment. One patient hassince declined treatment until May and the others wereall reviewed in February 2017.

• Some elective patients were admitted directly to thesurgical admissions suite where they were prepared fortheatre. They were then taken to a ward post operation.The aim of the admissions suite was to help improve theflow of patients through the hospital by giving the wardsextra time to discharge patients to free up beds. Thisunit was open from Monday to Friday, from 7am to 5pm.

• Due to pressure on beds, the trust had been using theday surgery unit as an inpatient ward. This had alsobeen taking place at our last inspection. The action planthe trust sent us after our last inspection stated thatfunding for trust staff had been agreed from Mondaymorning until Saturday lunchtime, however staff told usthe unit was open full time. However, we noted the unitdid close over the Christmas period.

• There was an updated escalation plan used when thehospital was experiencing pressures on beds. Thisstated that patients would not be placed on the daysurgery unit if they were going to be in hospital forlonger than 24 hours. However, this was not alwayshappening. We spoke to several inpatients that hadbeen on the day surgery unit for longer than 24 hours.We received some feedback from patients prior to thisinspection about being cared for on the day surgery unitwho felt their needs were not being met, such asmedication not sent with them from the ward they weretransferred from and limited space.

• From April 2015 to September 2016, the trust’s bedoccupancy has been consistently higher than theEngland average by between 2 and 8%. This put extrapressure on their services and beds.

• Between April 2015 and March 2016, the average lengthof stay for surgical elective patients at the trust was 3.3

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days, compared to 3.3 days for the England average. Forsurgical non-elective (emergency) patients, the averagelength of stay was 5.0 days, compared to 5.1 for theEngland average.

• At Gloucestershire Royal Hospital, the average length ofstay for elective patients was 2.8 days (lower than theEngland average) and 4.8 days for non-elective(emergency) patients (lower than the average). Thenon-elective specialty trauma and orthopaedics had thehighest average length of stay at 7.8 days but was lowerthan the England average of 8.8 days.

• Each speciality was responsible for devising theatre lists.The staff ere spoke with told us they had been doing thisjob for a long time and as a result were aware of howlong operations took. Patients were added to thewaiting list by the clinicians and they were assessed tosee if the operations were urgent. Staff liked to have listscompiled well in advance so they could be sent totheatres to make sure equipment was ordered andstaffing in place. However, with the new computersystem this process was taking longer so operation listswere not compiled so far in advance. There was noreports of any issues for patients

• In the two weeks leading up to our inspection allelective orthopaedic surgery had been cancelled as theward was being used as a medical ward as part of theescalation plans. Staff in theatres told us the onlyoperations taking place were for patients with cancer,identified as urgent, or patients who had been cancelledon two previous occasions. At the time of the inspection,staff were waiting to hear when the ward would bereturned to surgery so they could book patients in fortheir operations.

• Since November 2016, there had been seven timeswhere patients had been nursed in recovery as therewere no HD beds available. Day surgery patients werealso discharged directly from recovery as the daysurgery unit as being used for inpatients. Staff said ofthe 19 beds in recovery they had only five that theywould call active recovery beds.

• One patient told us they had their operation cancelledtwice before finally having it at the time of ourinspection. However, they were happy with theirexperience once admitted and were pleased to havehad their operation.

• On the last day of our inspection, we observed thecancelation of one patient’s elective operation due to an

emergency admission. We asked the matron in theatreswhy this was had occurred but they were not aware ofthe cancellation. It was unclear who had made thedecision to cancel the patient. On further investigation,it was apparent that there might not have been a needto cancel the patient if the overall utilisation of thetheatre suite had been taken into account, as there wascapacity to take the patient onto another theatre list. Bythe time this was identified, the patient had drunk. Thepatient was offered another date immediately.

• On the day of our unannounced inspection, there weresix elective operations cancelled. Staff said they did notcancel patients whose operations were due to cancerand would try their best not to cancel patients who hadbeen cancelled previously.

• Wards 3a, 3b and 5a told us during our unannouncedinspection they had been experiencing issues withgetting their medical outlying patients reviewed bymedical doctors. They had escalated this to senior staff.All the surgery wards we visited during ourunannounced inspection had medical outlying patientson them.


• Services were planned to take account of the needs ofdifferent people. For example, staff had access totranslation services, both in person and by thetelephone. A member of staff told us about a patientwho had surgery during our inspection who had aninterrupter with them.

• A learning disability liaison team supported staff to carefor and support patients with complex needs and theircarers during their stay in hospital. Carers were able tostay with them and join them in recovery following theiroperation.

• Patients living with dementia were identified by the‘purple butterfly scheme’, which indicated to staff theyneeded more support. Staff in theatres and recoveryhad devised guidance for staff to follow. For example, inrecovery, patients were to be admitted into the quietand calm bays and overhead lighting was kept to aminimum. The patient’s family member or carer wasalso able to be with them in recovery if needed.

• Staff in recovery also had access to ‘twiddlemitts’ forpatients living with dementia. Twiddle mitts are basicknitted hand muffs with items attached such as large

Surgery

Surgery


buttons or knitted flowers, which a patient can 'twiddle'in their hands. These were used to reduce patientsstress when they were faced with a situation that wasunknown to them.

• Staff told us there was little food provision outside ofmeal times, for example, if a patient was in theatre or offthe ward for an investigation, they would have to havesandwiches, toast or cereals. The majority of patientstold us the food was good. However as the meals wereordered a day in advance they could not always cater foralternative dietary requirements. For example, on theday surgery unit one patients was a vegetarian but theydid not have any meals left suitable for them. The trusttold us following our inspection that the central kitchenwas open 24 hours a day and staff from the wards couldrequest food for patients from them.

• At our last inspection staff on the day surgical unit toldus they often had difficulties in accessing other servicesfor patients, for example specialist diabetic nurses andphysiotherapists. At this inspection, staff told us this hadimproved and we saw physiotherapists, occupationaltherapists assessing, and reviewing patients.

• As the day surgery unit was being used as a ward stafftold us that at weekends they had no domestic toprovide patients with refreshments, for example to cleanand replace their water jugs. This was left to the staff onthe unit but if they were busy, it was often missed.However patients were not left without access to drinks.A senior member of trust staff told us the unit was ableto arrange this but it was clear from talking to staff onthe unit they were not aware they did this. There werealso issues with maintaining privacy and dignity on theday surgery unit in the main female bay as the nurses’station was positioned in the area. Due to lack of space,patients were able to hear for example, nurses on the

telephone, doctors talking to other patients and to otherstaff. However, two patients told us the night staff didtheir very best to keep noise level to a minimum at nightso they could get some sleep.


• Patients we spoke with knew how to make a complaintor raise concerns and they were confident to speak up.The majority were happy with the care they hadreceived and did not feel they needed to make acomplaint. Patients told us that if they wanted to makea complaint they would speak with a member of thenursing staff. The trust’s complaints and commentsprocedure was displayed on noticeboards around someof the surgery wards, departments and units.

• Patients’ concerns and complaints were used to helpimprove the quality of care. Complaints were discussedat ward and divisional level. Staff told us learning fromany complaints was shared with staff.

• From November 2015 to October 2016, there were 108complaints about surgical care. The trust took anaverage of 39 working days to investigate and closecomplaints, which was not in line with their complaintspolicy, which states complaints should be responded toin 35 working days. The trust’s internal standard states95% of cases should be responded to within 35 workingdays.

• Patient care was the most complained about themewith 30 complaints, followed by clinical treatment with16 complaints. The profession ‘nursing’ received 51complaints.

• Gloucestershire Royal hospital received 71 complaints ofwhich patient care received the highest number ofcomplaints, 20 (28%). In contrast, Gloucestershire RoyalHospital as a whole for this period received 651complaints and of these, patient was care was thehighest at 114 (18%).

Surgery

Surgery



Overall

Information about the serviceMaternity and gynaecological services provided byGloucestershire Hospitals NHS Foundation Trust arelocated on two hospital sites, Gloucestershire RoyalHospital and Cheltenham General Hospital. In addition,maternity services are also provided at Stroud Hospital.However, services on all sites are run by one managementteam (within the women’s and children’s division) and, assuch, are regarded within the trust as one service.

Gloucestershire Royal Hospital provides maternity andgynaecological services to the local community and thesurrounding areas. Gynaecological care is provided in a 13bed gynaecological ward (Ward 9a) and a gynaecologicaloutpatient area which also provides an early pregnancyassessment service. On-site gynaecological theatres arerun and managed by the surgical division.

Midwife-led and obstetrician-led services are provided forearly pregnancy, antenatal, induction of labour, deliveryand postnatal care, along with community care including ahome birth service. There is an antenatal clinic thatincludes a day assessment unit, which has six recliningchairs and one couch. Inpatient care is provided on thematernity ward (46 beds providing both antenatal andpostnatal care in a mixture of side rooms and four-beddedbays). The delivery suite consists of a triage area with fivebeds and 12 birthing rooms. One room is equipped with apool and is promoted for use by high risk womenrequesting a more normal birth experience. There is abereavement suite that has a delivery bed, a lounge area,en-suite facilities and a kitchenette. There is access to thesuite from outside of the labour suite. Two rooms are alsoused to provide high dependency care, though they canalso be used as birthing rooms, and another of the rooms isused to admit women awaiting elective caesarean section(all rooms other than the latter being en suite). The theatresuite adjacent to the delivery suite has two dedicatedobstetric operating theatres and a four bed recovery area.In addition, midwife-led care is provided in the birth unit onthe floor above the main obstetric unit. It has six birthingrooms, two of which are equipped with pools.


Obstetric and specialist clinics are run by obstetricians andother specialist consultants, for example diabetologistsand anaesthetists. Antenatal clinics are held from Mondayto Friday.


Maternity and gynaecology


Summary of findings• All areas had access to emergency resuscitation

trolleys. However, in some areas, a systematic checkof the trolleys was not documented as having beingcarried out on a daily basis. There were no up to dateResuscitation Council (UK) guidelines available onthe resuscitation trolleys. Intravenous fluids on theemergency resuscitation trolleys were not storedsecurely to ensure they were tamper proof. Thismeant staff could not be assured the rightequipment and guidance would be available in thecase of an emergency.

• Not all drug storage fridge temperatures weredocumented daily. There was no process in place if atemperature fell outside of acceptable limits. Thismeant staff could not be assured medicines requiringrefrigeration were being stored at the requiredtemperatures.

• There were a number of out of date patient groupdirectives (PGD’s) in use in maternity services. Thelists of medicines that were subject to PGD’s had nodoses or route of administration detailed on them.We drew this to the attention of senior staff and thePGD’s were removed from use.

• Community midwives could not always print outclinical notes from the electronic system to go intowomen’s handheld notes. They also reported poormobile phone coverage which meant there wassometimes a delay in getting messages. This couldhave an impact on a woman who was trying to getsome help or advice from a midwife. The trust told uswomen were always asked to contact maternitytriage in the first instance if they had any concerns.This was available 24 hours a day and was notreliant on mobile phone coverage.

• An electronic patient record system had beenintroduced trust wide in December 2016. There weresome ongoing issues with allocation of baby NHSnumbers and records migrating to the new system.This meant that babies may miss out on vital testsfollowing birth. Midwives had devised solutions toensure each baby had an NHS number.

• There were often long waiting times in the triagearea. Whilst systems were being put in place to

increase medical and midwifery staffing, womenwere not seen within 15 minutes of attending theunit. This could mean that urgent issues may bemissed.

• Consultant presence, on labour suite, was below therecommendations of the Royal College ofObstetricians and Gynaecologists (RCOG) SaferChildbirth (2007) guidance.

• Speciality trainee doctors (ST3 and ST4) and someconsultants felt that a senior house officer equivalentwas needed at night as sometimes no other medicalstaff to assist with emergency caesarean sectionswere available. This also meant other patients,across maternity and gynaecology services, whoneeded to see a doctor sometimes had to wait forlong periods of time.

• The morning medical handover was informal andthere was no input from the co-ordinating midwifeabout the women in labour at the time of themeeting. The registrar who had been on dutyovernight presented the cases but said they wereoften tired and did not always have the full up todate details of the women. This may mean that themost up to date information is not being given to thenext staff coming on duty.

However:

• Staff understood their responsibilities to raiseconcerns and report incidents using the electronicreporting system. There was a culture of sharedlearning from incidents.

• Staff spoke confidently about the duty of candourand gave examples of where it had been applied.Relevant staff had received training.

• All areas we visited were visibly clean and tidy. Therewere antibacterial hand sanitizers at the entrances toeach unit/ward. Staff were seen adhering to thetrusts infection control policies including ‘bare belowthe elbows”. This meant people visiting the maternityservices were protected from the spread of infection.

• All rooms on the delivery suite, including the triagearea had wireless cardiotochograph (CTG) machinesfor monitoring the foetal heart. The CTG machines




were linked to a central monitor point, whichallowed the co-ordinating midwife to review traces.The wireless aspect meant women could still bemonitored whilst in a birthing pool.

• Doors into all wards/units were locked, with a buzzerentry system and CCTV. Although reception areaswere not manned 24 hours per day; when there wasno receptionist other staff on duty took on the role. Ababy security tagging system was in place on thematernity unit.

• There were systems in place for recognising andreporting safeguarding concerns. Staff wereconfident to raise any matters of concern andescalate them as appropriate.

• A ‘vulnerable women’s team’ had been developedthat included a 0.85 whole time equivalent (34 hoursa week) perinatal mental health midwife, substancemisuse and teenage pregnancy midwife and the leadsafeguarding midwife. The team were able to offer anenhanced service to those women identified as beingat risk. The team also offered advice and support tomidwives who had concerns.

• Staff said there was good access to mandatorytraining. Mandatory training for maternity servicesincluded a PROMPT (Practical ObstetricMulti-Professional Training) skills drills training dayand a one-day maternity update for staff workingwithin the maternity unit.

• The maternity services offered Birth Choices Clinic forwomen identified as being high risk but whorequested midwife-led care. They were seen by asupervisor of midwives and a complex care plandevised in agreement with the woman and indiscussion with an obstetrician.

• The service had a commitment to managingwomen’s peri-natal mental health issues and weretrying to establish a team to include a consultantpsychiatrist.

• The development of a training package for midwivesto enable them to administer flu vaccinations to atrisk women had meant that a high number of womenwho would otherwise have not had the flu vaccinehad received it.

• The gynaecology ward had been relocated, inDecember 2016, to a ward with less beds (20 beds to13 beds) to reduce the incidence of outlying patients

(that is patients from medical or surgical wards)which sometimes meant elective gynaecologysurgery had to be cancelled. The ward sister said thenumber of outliers had reduced significantly and as aresult there were less elective gynaecologyprocedures being cancelled.


• A telephone triage system staffed by midwives waslocated within an ambulance service hub. Midwivesdirected women to the most appropriate place fortheir care. The system had reduced the volume ofcalls directly to the triage area.

• There was 24-hour consultant on-call cover. Thedelivery suite had access to anaesthetists 24 hours aday, seven days a week. Doctors we spoke with saidthat consultants always came in at night if they wereasked to.




Are maternity and gynaecology servicessafe?



• All areas had access to emergency resuscitation trolleys.However, in some areas, a systematic check of thetrolleys was not documented as having being carriedout on a daily basis. There were no up to dateResuscitation Council (UK) guidelines available on theresuscitation trolleys. Intravenous fluids on theemergency resuscitation trolleys were not storedsecurely to ensure they were tamper proof. This meantstaff could not be assured the right equipment andguidance would be available in the case of anemergency.

• Not all drug storage fridge temperatures weredocumented daily. There was no process in place if atemperature fell outside of acceptable limits. Thismeant staff could not be assured medicines requiringrefrigeration were being stored at the requiredtemperatures.

• There were a number of out of date patient groupdirectives (PGD’s) in use in maternity services. The listsof medicines that were subject to PGD’s had no doses orroute of administration detailed on them. We drew thisto the attention of senior staff and the PGD’s wereremoved from use.

• Community midwives could not always print out clinicalnotes from the electronic system to go into women’shandheld notes. They also reported poor mobile phonecoverage which meant there was sometimes a delay ingetting messages. This could have an impact on awoman who was trying to get some help or advice froma midwife. The trust told us women were always askedto contact maternity triage in the first instance if theyhad any concerns. This was available 24 hours a day andwas not reliant on mobile phone coverage

• An electronic patient record system had beenintroduced trust wide in December 2016. There weresome ongoing issues with allocation of baby NHSnumbers and records migrating to the new system. Thismeant that babies may miss out on vital tests followingbirth. Midwives had devised solutions to ensure eachbaby had an NHS number.

• There were often long waiting times in the triage area.Whilst systems were being put in place to increasemedical and midwifery staffing, women were not seenwithin 15 minutes of attending the unit. This couldmean that urgent issues may be missed.

• Consultant presence, on labour suite, was below therecommendations of the Royal College of Obstetriciansand Gynaecologists (RCOG) Safer Childbirth (2007)guidance.

• Speciality trainee doctors (ST3 and ST4) and someconsultants felt that a senior house officer equivalentwas needed at night as sometimes no other medicalstaff to assist with emergency caesarean sections wereavailable. This also meant other patients, acrossmaternity and gynaecology services, who needed to seea doctor sometimes had to wait for long periods of time.

• The morning medical handover was informal and therewas no input from the co-ordinating midwife about thewomen in labour at the time of the meeting. Theregistrar who had been on duty overnight presented thecases but said they were often tired and did not alwayshave the full up to date details of the women. This maymean that the most up to date information is not beinggiven to the next staff coming on duty.

However:

• Staff understood their responsibilities to raise concernsand report incidents using the electronic reportingsystem. There was a culture of shared learning fromincidents.

• Staff spoke confidently about the duty of candour andgave examples of where it had been applied. Relevantstaff had received training.

• All areas we visited were visibly clean and tidy. Therewere antibacterial hand sanitizers at the entrances toeach unit/ward. Staff were seen adhering to the trustsinfection control policies including ‘bare below theelbows”. This meant people visiting the maternityservices were protected from the spread of infection.

• All rooms on the delivery suite, including the triage areahad wireless cardiotochograph (CTG) machines formonitoring the foetal heart. The CTG machines werelinked to a central monitor point, which allowed theco-ordinating midwife to review traces. The wirelessaspect meant women could still be monitored whilst ina birthing pool.

• Doors into all wards/units were locked, with a buzzerentry system and CCTV. Although reception areas were




not manned 24 hours per day; when there was noreceptionist other staff on duty took on the role. A babysecurity tagging system was in place on the maternityunit.

• There were systems in place for recognising andreporting safeguarding concerns. Staff were confident toraise any matters of concern and escalate them asappropriate.

• A ‘vulnerable women’s team’ had been developed thatincluded a 0.85 whole time equivalent (34 hours aweek) perinatal mental health midwife, substancemisuse and teenage pregnancy midwife and the leadsafeguarding midwife. The team were able to offer anenhanced service to those women identified as being atrisk. The team also offered advice and support tomidwives who had concerns.

• Staff said there was good access to mandatory training.Mandatory training for maternity services included aPROMPT (Practical Obstetric Multi-Professional Training)skills drills training day and a one-day maternity updatefor staff working within the maternity unit.

• The maternity services offered Birth Choices Clinic forwomen identified as being high risk but who requestedmidwife-led care. They were seen by a supervisor ofmidwives and a complex care plan devised inagreement with the woman and in discussion with anobstetrician.

• The service had a commitment to managing women’speri-natal mental health issues and were trying toestablish a team to include a consultant psychiatrist.

• The development of a training package for midwives toenable them to administer flu vaccinations to at riskwomen had meant that a high number of women whowould otherwise have not had the flu vaccine hadreceived it.

• The gynaecology ward had been relocated, in December2016, to a ward with less beds (20 beds to 13 beds) toreduce the incidence of outlying patients (that ispatients from medical or surgical wards) whichsometimes meant elective gynaecology surgery had tobe cancelled. The ward sister said the number ofoutliers had reduced significantly and as a result therewere less elective gynaecology procedures beingcancelled.


• A telephone triage system staffed by midwives waslocated within an ambulance service hub. Midwivesdirected women to the most appropriate place for theircare. The system had reduced the volume of callsdirectly to the triage area.

• There was 24-hour consultant on-call cover. The deliverysuite had access to anaesthetists 24 hours a day, sevendays a week. Doctors we spoke with said thatconsultants always came in at night if they were askedto.

Incidents

• Staff understood their responsibilities to raise concernsand report incidents using the electronic reportingsystem.

• A trust-wide list of incident categories andmaternity-specific categories was in use. This gave staffclear guidance on what constituted an incident, forexample third and fourth degree tears, any unplannedadmission to the neonatal unit, and postpartumhaemorrhage.

• Ten serious incidents (SI’s) had been reported within thematernity services since August 2015. These had beeninvestigated, and actions were monitored through thematernity clinical governance meeting. Staff were ableto describe changes that had occurred as a result, forexample the introduction of a stamp when a highvaginal swab (HVS) was taken and a paper copy of theresults sent to the clinic to ensure results were actedupon. The importance of the use of the green ‘cause forconcern’ forms had been introduced into midwivesinduction programme and included on mandatorytraining; this improved access to previous notes.

• There were four SI’s in an eight week period so thematernity services asked for a trust level review. Thiswas carried out and no themes were identified.

• Less serious incidents were investigated at ward anddepartment level by the midwife or nurse with leadresponsibility for that area. All incidents described asmoderate were reviewed by the lead nurse/midwife forquality and governance. The gynaecology nurseconsultant reviewed and commissioned a root causeanalysis for any moderately rated incidents. Actionsidentified were monitored for completion through thematernity clinical governance and the gynaecologicalclinical governance groups. These were fed into thedivisional board governance meetings.




• Unplanned admissions to the neonatal unit werereported as incidents. These were investigated andtrends monitored via the maternity service dashboard.

• Community midwives could not always print out clinicalnotes from the electronic system, to go into women’shandheld notes. The midwives said they reported this asan incident when it happened as it could impact on theinformation about the woman and her pregnancyavailable to other professionals who needed to look atthe notes.

• When an incident was described as ‘red’ (meeting thetrust’s threshold as a serious incident requiringinvestigation), the lead nurse/midwife for quality andgovernance, senior managers and clinicians undertooka rapid review and escalated the incident to trust level.Investigators were then identified, including someoneexternal to the division, and a full investigation tookplace. Actions identified were monitored for completionthrough the maternity clinical governance and thegynaecological clinical governance groups. These fedinto the divisional board and onward to the trust-widesafety experience review group, which was a sub-groupof the board with overall responsibility to review safetymeasures in place.

• Lessons learned following investigated incidents weredisseminated via the monthly ‘team talk’ bulletin. Therisk managers were involved in mandatory trainingsessions so were able to discuss risks and they alsocirculated ‘lessons learnt’ to staff via email to reach awider audience. Risk management meetings includedthe consultant lead for risk, matrons, supervisors ofmidwives and risk midwives. The minutes werecirculated to all staff.

• Minutes from the Maternity Risk management meeting(September 2016) detailed a variety of cases fordiscussion. The minutes were also seen by the SafetyExperience Review Group (SERG) and then by divisionalleads who agreed the action plans formally.

• Morbidity and mortality meetings were held monthly,where cases were reviewed and outcomes discussed forlearning. These were attended by medical staff, seniormidwives and risk midwives and any learning cascadedto the relevant staff.

Duty of Candour

• Staff spoke confidently about the duty of candour andgave examples of where it had been applied. Relevantstaff had received training.

• Regulation 20 of the Health and Social Care Act 2008(Regulated Activities) Regulations 2014 is a regulation.This Regulation requires the trust to be open andtransparent with a patient when things go wrong inrelation to their care and the patient suffers harm orcould suffer harm, which falls into defined thresholds

• We reviewed investigations into incidents and foundthat a ‘Duty of Candour’ letter was sent to the patient.

Safety thermometer

• The gynaecology ward and the maternity unitparticipated in the NHS Safety Thermometer. This was aprocess to collect information with respect to patientsafety related to falls, catheters, urinary tract infectionsand pressure sores. These rates were in line with theEngland average. Patient safety information wasdisplayed in clinical areas for patients, visitors or staff tosee.

• Maternity services had taken part in the new maternityspecific NHS Safety Thermometer, which was to take theplace of the general NHS Safety Thermometer formaternity services. There were not yet any resultsavailable.


• Incidences of infection were reported as required.

• All areas we visited were visibly clean and tidy. We weretold there was a system in place for washing of linencurtains and this was arranged by the linen team,although we did not see any documentation to supportthis. We saw disposable curtains in some areas. Thesehad dates that indicated when they were next to bechanged.

• Antibacterial hand cleanser was available at theentrances to all the wards and departments, birthingrooms and consulting rooms.

• Staff were seen adhering to the trusts infection controlpolicies including ‘bare below the elbows”, handwashing between patients and the use of personalprotective equipment such as gloves and disposableaprons.

• All consulting rooms had hand washing sinks thatcomplied with Health Building Note 00-09: Infectioncontrol in the built environment (3.29 – 3.34). They also




had liquid soap, paper hand towels and pedal bins. Wewere told consulting couches were cleaned in betweeneach patient and saw antibacterial wipes and rolls ofpaper sheets in each room to support this.

• There was a sticker system in place that indicated whena piece of equipment had been cleaned. We saw severalpieces of equipment with the stickers in place.

• Birthing pools, on delivery suite and on the birthing unit,were cleaned between cases with a suitable detergentfollowing trust policy and guidance, although there wasno record made of the cleaning. Daily flushes of thebirthing pools were recorded.

• We looked at cleaning schedules in a variety of areas wevisited. They had been signed as completed. Staff toldus they had regular cleaning staff who knew how tomanage their particular area.

• We saw that Sepsis 6 (a bundle of medical therapiesdesigned to reduce the mortality of patients with sepsis)was well promoted and staff we spoke with had a goodawareness of the subject.

• Cleaning of the obstetric theatres between cases wascarried out by health care assistants from the deliverysuite. General obstetric theatre cleaning was carried outby the general theatre team.

• On ward 9a (gynaecology) there was carpet along thecorridors. This was in place when the ward wasrelocated from ward 2a. The ward sister told us it hadbeen risk assessed and there was a cleaning schedule inplace. The carpet was being removed and more suitableflooring laid in March 2017.

• Cases of methicillin-resistant Staphylococcus aureus(MRSA) and Clostridium difficile rates were within anacceptable range were within the accepted range.Maternity services were not identified as outliers forthese infections.


• Emergency call bells were available on the wards and inindividual consulting rooms.

• All areas had access to emergency resuscitation trolleys.However, in some areas, a systematic check of thetrolleys was not documented as being carried out on adaily basis, as required by trust policy andrecommended by The Resuscitation Council (UK). Insome areas at low risk of emergencies, for example the

ante natal clinic, the trust policy allowed for weeklychecking and this was consistently completed. Therewere no up to date Resuscitation Council (UK)guidelines available on the resuscitation trolleys.

• There was a postpartum haemorrhage (PPH) emergencytrolley, stored in the recovery room on the delivery suite.There was up to date guidance about emergency PPHmanagement with the trolley.

• Staff reported they had access to up to date equipmentand equipment was fixed quickly once reported asfaulty. All equipment we saw had stickers on themidentifying when they had last been serviced/calibrated.

• All rooms on the delivery suite, including the triage area(since January 2017) had wireless cardiotochograph(CTG) machines for monitoring the foetal heart. The CTGmachines were linked to a central monitor point, whichallowed the co-ordinating midwife to review traces. Thewireless aspect meant women could still be monitoredwhilst in a birthing pool.

• The triage area had equipment to safely monitor andassess pregnancy. An ultrasound machine was availableto confirm the presence or absence of a foetal heartbeatand was also used to confirm the position of a baby.

• There was access to bariatric equipment (used forwomen with high body mass index) throughout thematernity services at Gloucester Royal Hospital.

• Birthing rooms and bed spaces on the wards had pipedoxygen and suction available. Staff said there weresufficient numbers of resuscitaires available forneonatal resuscitation.

• Rooms in the birth centre were large and had a calmingatmosphere; they had subdued lighting and non-flamecandles (LED). Birth couches were provided rather thanbeds. Two rooms were equipped with birthing pools. Inaddition there were birthing stools, balls and matsavailable to facilitate mobility in labour. Most of therooms there also had ‘pull down’ double beds, whichmeant partners were able to stay overnight. All roomshad en suite facilities. Emergency evacuationequipment was available for use in the event of amaternal collapse in the pool. Transfers out of the poolwere practised, and manual handling was included inmandatory training for all maternity staff.

• Partners were able to stay with women on the deliverysuite, but there were no facilities for them to remainovernight after birth, with the exception of bereavedparents. The two bereavement rooms were equipped




with sofa beds to allow partners to stay. In addition, theyhad toilet facilities and kitchen area where drinks couldbe prepared. A cold cot was available if bereavedparents wanted to spend time with their baby. Thebereavement rooms could be accessed independentlyof the delivery unit.

• Equipment was serviced regularly by the trust’smaintenance department. They held an inventory ofwhat equipment areas had and when it was due to beserviced/calibrated. We saw the service dates on avariety of pieces of equipment, including pumps,resuscitaires and monitors.

• Doors into all wards were locked, with a buzzer entrysystem and CCTV. Reception areas were not manned 24hours per day; when there was no receptionist otherstaff on duty took on the role.

• A baby security tagging system was introduced in 2015in order to increase the security of babies within thematernity unit. This was reported as working well.

• Community midwives reported poor mobile phonecoverage which meant there was sometimes delay ingetting messages. The trust told us women were alwaysasked to contact maternity triage in the first instance ifthey had any concerns. This was available 24 hours aday and was not reliant on mobile phone coverage.Connectivity issues meant communitymidwives sometimes had to return to base to log workand carry out administrative tasks on online, whichmeant their working days were often extended. Thisrelated to mobile lap top computers. New computershad been ordered but had not yet been delivered.

Medicines

• Not all medicines were securely stored. Medicinecupboards were locked on all wards and departments,however, intravenous fluids on the emergencyresuscitation trolleys were not securely stored.Medicines stored on adult and neonatal emergencyresuscitation trolleys were stored within tamper-evidentcontainers.

• Some rooms, that contained medications, were securedwith digital keypads. However, the codes for these wererarely changed.

• Drug storage fridge temperatures were documenteddaily. However on the maternity ward there were dayswhen the temperatures had not been recorded: October2016 – 11 days, November 2016 – 4 days, December

2016 – 9 days and January 2017 – 6 days. There was noprocess in place if a temperature fell outside ofacceptable limits. For example on the labour suite thefridge was between 12 and 18 degrees on nineconsecutive days with no note of any action taken.

• Midwives were able to administer some medicinesunder patient group directives (NHS documentspermitting the supply of prescription only medicines togroups of patients without individual prescriptions).Training for this was included during the midwives’preceptorship programme and included in mandatorytraining updates. However we saw some out of datePGD’s in use in maternity services. For example lists ofmedicines that were subject to PGD’s with no doses orroute of administration. We drew this to the attention ofsenior staff and out of date information was removedfrom use. However, the trust told us the official PGDwebpage contained up to date PGD's for staff to use.The trust head of pharmacy had an action plan toreview and update all PGDs. Stated to be completed byApril 2017. We were not made aware of what staff werereferring to in the interim period, there was someconfusion over where, on the system, maternity stafflooked for relevant PGD's.

• In one of the post-natal patient records we reviewedthere was no review or stop date for a prescribedantibiotic and no General medical Council (GMC)number or bleep number detailed and the signaturewas illegible.

• There was an on-call pharmacy service for supply andadvice outside of pharmacy opening hours.

• There was a facility on the intranet for staff to see whatmedicines were stocked around the hospital to helplocating medicines when the pharmacy was closed.

• A rolling replacement of resuscitaires with blendedgases was ongoing. This would ensure all resuscitairesacross the maternity services would be the samereducing the risk of confusion. This had been an item onthe risk register since 2014.

Records

• During the inspection we looked at 12 sets of patientrecords. They included detailed risk assessments forexample ante natal venous thromboembolism (VTE)assessments, mental health assessments, modified




early obstetric warning system (MEOWS) completed postnatally and allergy details. However in two of the threepost-natal notes reviewed there was no inpatient VTErisk assessment completed.

• Women carried their own records for the duration of thepregnancy. Once delivered, women were issued withtheir postnatal records to enable their ongoing care/support to be documented and a child health record(red book) for their baby.

• There was good access to previous medical records. Wesaw that previous records were routinely obtained whena woman booked for her care during pregnancy.

• Midwives conducted audits of record keeping as part oftheir annual supervisory review. Their records wereaudited and reviewed by their supervisor any actionsrequired were identified. The trust was planning amodel of midwifery supervision to use to ensure thesepractices continued when the statutory supervision ofmidwives ceases to be a legal requirement in 2017.

• An electronic patient record system had beenintroduced trust wide, in December 2016. There weresome ongoing issues with allocation of a baby NHSnumbers and records migrating to new system. Howevera workaround had been developed and staff were ableto ensure all babies had an NHS number.

Safeguarding

• Staff received training in safeguarding vulnerable adultsand children. Where appropriate, staff within thematernity service were trained to safeguarding level 3.Staff on the gynaecology ward had safeguarding trainingto level 1 or 2, dependent upon their role. The trust set atarget of 90% for completion of safeguarding training.Midwifery and nursing staff met their target, with 93% ofstaff having completed adult and children safeguardingawareness training, 93% had completed level 2safeguarding adults training and 91% had completedlevel 2 safeguarding children training. Medical staff hadalso met their target, with 100% having completedsafeguarding children level 1 and 3 and 90% havingcompleted safeguarding adult’s level 1 and safeguardingchildren level 2.

• There were systems in place for reporting safeguardingconcerns. Midwives described how they would raiseconcerns. Staff were confident to raise any matters ofconcern and escalate them as appropriate. Informationwas available to staff in all areas we visited on how toescalate safeguarding concerns.

• Systems were in place to identify women and babies atrisk. This included the use of a ‘green form’, filed in theconfidential section of the maternity notes, that detailedany safeguarding concerns or other vulnerabilities suchas learning difficulties.

• A ‘vulnerable women’s team’ had been developed thatincluded a 0.85 whole time equivalent (34 hours a week)perinatal mental health midwife, substance misuse andteenage pregnancy midwife and the lead safeguardingmidwife. The team were able to offer an enhancedservice to those women identified as being at risk. Theteam also offered advice and support to midwives whohad concerns.

• Midwives were offered a vulnerable women training daythat was said to be well attended. Safeguarding trainingcovered female genital mutilation, child sexualexploitation and PREVENT (counter-terrorismawareness).

• Midwives attended safeguarding case conferences andstrategy meetings in partnership with the local authoritywhere appropriate. Information about women/familieswhere there were safeguarding concerns was written ona white board in the sister’s office on delivery suite.However it could not be seen by people passing theoffice. The same information was kept in a red folder onthe delivery suite to help to maintain confidentiality.Access to the safeguarding database was available toband 7 midwives and above, for confidentialitypurposes. This was kept updated by the 'vulnerablewomen's team' (VWT) who ensured a monthly updatewas sent to team leaders to enable planning for high riskcases. Midwives requiring additional information couldcontact the VWT or line managers at any time (a band 7midwife was available within the trust 24 hours a day).

• Community midwives said there was a safeguardingforum that team leaders attended. The forum was alsoopen to all midwives who wanted to attend. They addedthere was sometimes a lack of information sharing fromthe local social services. This had been escalated to themidwife safeguarding lead.

Mandatory training

• The trust had set a target of 90% for completion ofmandatory training. As of October 2016 the target wasmet in eight out of 12 modules for midwifery andnursing staff and included basic adult resuscitation,infection control and safety awareness. The fourmodules that did not meet the target (conflict




resolution, manual handling practical, manual handlingtheory and medicines management) had compliancerates of 82- 89%. The target in October 2016 was met in11 out of 12 modules for medical staff and includedprescribing, conflict resolution and basic adultresuscitation. The one module that did not meet targetwas manual handling practical (85%).

• Staff said there was good access to mandatory training.Mandatory training for maternity services included aPROMPT (Practical Obstetric Multi-Professional Training)skills drills training day and a one-day maternity updatefor staff working within the maternity unit. The trainingcovered CTG training and peri-natal mental health. Thetrust employed practice development midwives, whomonitored attendance at mandatory training. Staff wereautomatically booked onto mandatory trainingannually. Failure to attend was escalated to managersfor action.

• Senior House Officers (SHO) did not attend PROMPTskills drills training when they started at the trust. Thosethat spoke to us said whilst they did not cover thedelivery suite they did carry an emergency bleep and ifthey arrived in the delivery suite first they often felt outof their depth. The trust told us that it was made clear tojunior doctors at the start of their attachment toobstetrics that management of patients on labour wardwas outside of their remit. However they recognised themessage was not as clear as it should have been andmore instruction about junior doctors responsibilitieswould be given to them within the first week of theirattachment to obstetrics.


• Staff used a communication tool known as RSVP(reason, summary, vital signs and plan). We observedhandovers following that format. We saw notes thatshowed that RSVP was followed to assess patients anddevelop a plan of care.

• The trusts annual birth unit report 2015 showed thataround 50% of women booked for maternity care inGloucestershire were booked for midwifery led care.Around 30% gave birth at home or in a midwife ledbirthing unit. This compared to a national average of13% (National Maternity Review 2015). This showedwomen were risk assessed appropriately before makinga decision to use a midwife led unit.

• The maternity services offered Birth Choices Clinic forwomen identified as being high risk but who requested

midwife-led care. They were seen by a supervisor ofmidwives and a complex care plan devised inagreement with the woman and in discussion with anobstetrician. These plans were stored within thewoman’s notes and also on the supervisor of midwives’shared computer drive to ensure each supervisor ofmidwives and all band 7 midwives were fully aware ofthe agreed plan of care. The midwife led birthing suitestaff participated in the clinics to help women decidewhere to have their baby.

• The service had a commitment to managing women’speri-natal mental health issues and were trying toestablish a team to include a consultant psychiatrist.The service recently appointed a 0.85 whole timeequivalent (34 hours a week) midwife to work only inperi-natal mental health. A visiting consultantpsychiatrist held a clinic session in the unit monthly andwas accessible to staff via email. Assessment of mentalhealth documentation in patient notes was auditedannually. A liaison psychiatric team was available dailybetween 8am and 10pm and then on call. There wasalso a crisis team available 24 hours a day seven days aweek. Although they usually worked in the communitythey would attend the hospital if necessary.

• Records we looked at showed the World HealthOrganisation 5 Steps to Safer Surgery checklists were inuse and completed in full.

• Activity in triage had steadily increased over the last fewyears. A maternity pathways review in 2014 highlightedtriage as an area that could have significant pressuresand sometimes meant women had to wait for longperiods of time to be seen and assessed. This increasedthe risk to the women and their baby. Two seriousincidents had occurred in the last two years that couldhave been avoided if the women had been seen morequickly. In October 2016 90% of women waited up to 30minutes to be seen, with 3% waiting longer than 60minutes. This was an improvement from September2016 when 83 % of women had to wait up to 30 minutesto be seen and 9% waited longer than 60 minutes. Atelephone advice line was set up, as a one year pilotbetween August 2015 and August 2016, to direct womento the most appropriate service. This enabled midwivesworking in triage to concentrate more on face to faceassessments. This was successful and funding has beenreceived to enable the service to continue. Additionallya bid for an extra midwife to work in triage wassubmitted to the trust. The maternity services have




been actively recruiting to the post. Until it could befilled, from March 2017 onwards, triage was going to bepart of the midwifery staff rotation to ensure staffstaffing levels were maintained. Having the CTGreadings now linked to a central monitoring point so theco-ordinating midwife could review the readings alsohelped to increase the safety of the triage system. Therewas a consultant obstetrician starting work in March2017 specifically to work in triage and co-ordinate theimplementation of the rapid assessment and treatment(RAT) pathway to ensure women were seen within 15minutes of arrival.

• Midwives practised ‘fresh eyes’ (an independent reviewof progress by a midwife not previously involved in thepatient’s care) on the delivery suite every two hours.This was undertaken by a core delivery suite midwife,usually the coordinating midwife who was not directlyinvolved in the woman’s care. It comprised a review ofthe foetal heart and progress in labour.

• Where risks had been identified antenatally, appropriatecare plans were developed. For example, staff describedcare of women with gestational diabetes, raised bodymass index (BMI) and co-existing medical problems.

• Public Health England (PHE) had asked maternity unitsto help with the uptake of flu vaccinations. The antenatal clinic sister had developed a training pack thatincluded PHE slides and anaphylaxis training, whichtook four hours to complete. The staff had to beobserved and signed off, to ensure competency. The fluvaccinations were then offered to women as part of theday to day work. This had seen significant numbers ofwomen have the vaccination in 2015/6 with a goodnumber continuing to have the vaccination in 2016/7.

• There were a limited number of midwives who hadundertaken additional courses in high dependency care.Where high dependency care was required followingdelivery, women were transferred to the highdependency unit, on the maternity unit, where therewas a midwife trained in high dependency care on dutyor the intensive care unit.

• Staff on the gynaecology ward and in the maternity unitcompleted the modified early warning score or NationalEarly Warning Score (NEWS) system for recording vitalsigns. This indicated to staff when observations requiredrepeating or concerns needed to be escalated. We sawevidence in notes we reviewed that concerns had beenescalated appropriately.

• The gynaecology ward had been relocated, in December2016, to a ward with less beds (20 beds to 13 beds) toreduce the incidence of outlying patients (that ispatients from medical or surgical wards) which hadsometimes meant elective gynaecology surgery had tobe cancelled. The ward sister said the number ofoutliers had reduced significantly and as a result therewere less elective gynaecology procedures beingcancelled.

• The gynaecology outpatients department held a nurseled early pregnancy clinic Monday to Friday 08.30amuntil 5pm and also on Saturday and Sunday mornings.There was access to the on call medical team. Thismeant women did not have to wait long to be seen ifthey had concerns. If women needed to be seen out ofhours they would be asked to go to the emergencydepartment.

• The medical induction of labour rate varied from 15.5%in May 2016 to 19.7% in October 2016. This was abovethe trust target of below 10% and slightly higher thanthe England average of 13.6%.

• All post-partum haemorrhages (PPH) above 1500mlstriggered a root cause analysis (RCA) investigation.Between April 2016 and November 2016 there had beenfour months where the numbers of PPH had been abovethe trust target of 3%. There had been no trendsidentified following the RCA’s.

• The average Caesarean section rate (for both electiveand emergency procedures) was 20.5% which wasbelow the trust target of 25%.

• The number of 3rd and 4th degree tears per operativevaginal births was above the trusts target of more than5% of all vaginal births, at 5.9% to 11.3% between Juneand October 2016. Although this was not classed as anoutlier according to the Royal College of Obstetriciansand Gynaecologists (RCOG), an audit was underwayduring the inspection and there was a plan toinvestigate techniques applied to see if any trends couldbe identified.

Midwifery staffing

• The Royal College of Obstetrics and Gynaecologyguidance (Safer Childbirth: Minimum Standards for theOrganisation and Delivery of Care in Labour, October2007), states there should be an averagemidwife-to-births ratio of 1:28. The fundedmidwife-to-births ratio was 1:29.5, which is worse thanthe England average of 1:29. The monthly maternity




dashboard reported the midwife-to-birth ratio againstestablishment (average of 1:29) and the actual staffinglevels that were an average of 1:31 which falls belowexpected levels. The trust did not include registeredmidwives who were not working clinically or any healthcare or midwifery care assistants in their data, as someother organisations did. Staff said midwife levels weresafe on delivery suite.

• In August 2016 the maternity services were 1.63% belowestablishment numbers. In November 2016 GloucesterRoyal Hospital reported a vacancy rate for maternity andgynaecology of 1.2%. We were told recruitment wasongoing.

• Midwives worked as core unit midwives, communitymidwives or rotational midwives within the mainhospital. Rotational midwives moved work areas everysix months, whilst core and community midwivesremained in the same working area. Triage was to beincluded in the rotation from March 2017.

• There were 10 midwives per shift on the delivery suite.This included one midwife who was assigned the role ofdelivery suite coordinator who worked in a supervisoryposition. At times of increased activity and in order toprovide one-to-one care to women in labour, staff wereredeployed from other areas of the maternity services.


• Midwifery and nursing handovers were at 08.30am and8.30pm, when staff changed shifts. The multidisciplinaryteam, not including medical staff, present on thedelivery suite attended the handover meetings.

• Acuity (patient dependency) was measured using thebirth rate plus acuity tool, with acuity monitoredfour-hourly. This meant midwifery managers were ableto benchmark staffing against patient dependency.

• The delivery suite had receptionist cover providedMonday to Friday, 8.30am to 10pm, and on Saturdaysfrom 9am to 5pm. Outside these times, all calls,administration and managing of access to the deliverysuite were the responsibility of the midwives on duty.This was often the midwife working in the triage area,meaning that sometimes the midwife was away frompatient care.

• Midwives were allocated to work in triage from thedelivery suite. Triage was staffed with one midwife atany one time and was open 24 hours a day, seven daysper week in addition, midwifery care assistant cover was

provided from 12.30 – 9pm. There were seven band 6midwives and one band 7 midwife who worked as thecore team on triage. From March 2017 midwife cover forthe triage area was to become part of the six monthlymidwife rotation meaning there would be increasedmidwife cover.

• A telephone triage system staffed by midwives waslocated within an ambulance service hub. Midwivesdirected women to the most appropriate place for theircare. The system had reduced the volume of callsdirectly to the triage area.

• A clear escalation policy detailed how additional staffwere to be obtained in the event of increased sicknessor high activity and/or acuity/dependency within thematernity services. This included additional supportfrom the senior midwifery team and supervisors ofmidwives and community midwives. The on-call rota foreach of these was displayed in the delivery suite. Whenstaff shortages occurred, incident forms were completedin order to monitor the frequency of such situations.

• The midwifery sickness rate across maternity andgynaecology services was 4.6% in December 2016.

• Expected and actual staffing levels were displayed onWard 9a (gynaecology), on the maternity ward,on delivery suite and on the birth centre. At the time ofthe inspection, the safe staffing information indicatedthere were the expected numbers of staff on each shifton Ward 9a. Gynaecology staff reported that staffinglevels had fluctuated recently as staff had left due to thepressure of large numbers of outlier patients (that ispatients from other specialities such as medicine andsurgery). That pressure had become much less since themove to ward 9a and staffing levels were now moreconsistent.

• The trust had a bank of nursing and midwifery staff. Thismeant there was little use of agency staff across thegynaecology service. The sister in gynaecologyoutpatients said it was difficult to get bank nurses tocover for their specialist service but sickness and leavewere usually covered by existing staff working extrashifts. Agency midwives were not used across maternityservices.

Medical staffing

• The trust reported 75 hours of dedicated consultantcover on the delivery suite. This was below therecommended 168-hour consultant presence to meet




the recommendations of the Royal College ofObstetricians and Gynaecologists (RCOG) SaferChildbirth (2007) guidance. However, staff told usconsultants attended when called out of hours and feltthe consultant presence on the delivery suite wascurrently at safe levels.

• The maternity services clinical scorecard between April2016 and November 2016 showed little use of locumconsultants with six out of the nine months using onewhole time equivalent (WTE) and three months usingtwo WTE.

• There was 24-hour consultant on-call cover. The deliverysuite had access to anaesthetists 24 hours a day, sevendays a week. Doctors we spoke with said thatconsultants always came in at night if they were askedto. They reported the on call rota was manageable andgaps were usually filled by existing staff. Consultantshad oversight of the on call rota. Speciality traineedoctors (ST3 and ST4) and some consultants felt that asenior house officer equivalent was needed at night assometimes there were no other medical staff to assistwith emergency caesarean sections which meant thescrub nurse had to assist. An example was given of awoman with a raised body mass index (BMI) of over 40who needed a caesarean section; the other ST gradedoctor was carrying out an instrumental delivery so wasnot available which meant the doctor had no medicalassistance. The midwife assisted until they had to ‘takethe baby’ and then a scrub nurse assisted. This hadhappened the previous night so had not been reportedas an incident at the time of the inspection. Thesituation also meant that gynaecology emergencies inthe emergency department sometimes had long waitsto be seen because the doctors were busy in deliverysuite and sometimes telephone advice had to be givento the maternity and gynaecological wards as there wasnot time to see the patient. The consultants and theRoyal College of Obstetricians and Gynaecologists(RCOG) were aware and funding for two extra posts hadbeen requested but not granted. The Severn Deanery(regional organisation responsible for postgraduatemedical training) was also aware stating that this wasthe only unit in their area to not have a senior houseofficer equivalent on call.

• The medical rota showed there was obstetric medicalpresence on the delivery suite 24 hours per day, sevendays per week.

• Medical handovers were at 8.30am, 1.30pm, 5.30pm and8.30pm on the delivery suite. We observed onehandover and saw it reviewed all patients following theRSVP (‘reason, summary, vital signs and plan’)communication format. This gave consistency andensured aspects of the patients’ care and planning wereincluded in discussions. The handover was informal andthere was no input from the co-ordinating midwifeabout the women in labour at the time of the meeting.The registrar who had been on duty overnight presentedthe cases but, registrars told us, they were often tiredand did not always have the full up to date details of thewomen.

• Medical staff from the delivery suite provided cover forthe triage unit and for women who had not beendischarged from the day assessment unit before itclosed. At times, these women waited for long periodsfor review. Staff told us accessing medical review couldbe difficult at times, particularly when the delivery suitewas busy. There was a consultant obstetrician startingwork in March 2017 specifically to work in triage andco-ordinate the implementation of the rapidassessment and treatment (RAT) pathway to ensurewomen were seen within 15 minutes of arrival.

• There were two obstetric theatres with senior nursesand operating department assistants from the generaltheatres team working alongside midwives andobstetricians. There were elective caesarean sectionlists between 8.30am and 4pm each weekday. Outsideof these hours, for emergencies, there was a generaltheatre team on call and on site. Women were recoveredfrom anaesthetic in the four bed recovery bay ondelivery suite. If a patient had higher dependency needspost operatively they may be recovered in generalsurgery recovery. The baby would stay on delivery suite.

• Out-of-hours medical cover was provided by registrarsand on-call consultants in both maternity andgynaecology. Reduced medical cover meant, at times, adelay occurred in a non-emergency review.


• Staff were aware of processes to follow in the event of amajor incident. The trust-wide major incident plan wasavailable to all staff on their intranet. The operationalpolicy for each maternity service had a section on the‘role in major incident’ and ‘business continuity andcontingency’. Each operational policy had a link to eachservice’s contingency plan.




• There was a maternity escalation policy for staff to use ifthere was a major event or high activity within the

maternity unit that could not be managed withavailable resources. It described steps to be taken todecide if the unit had to be closed and patients divertedto other units for a period of time.




Safe Good –––

Overall

Information about the serviceGloucestershire Hospitals NHS Trust provides inpatient andcommunity services for children and young people underthe age of 18 years. These include a neonatal unit locatedclose to the maternity services and a dedicated children’sunit in a different area of Gloucestershire Royal Hospital.

All children’s services are located at Gloucestershire RoyalHospital with the exception of specialist day case eyesurgery and some outpatient facilities. These services wereprovided at Cheltenham General Hospital but staffed bynurses from Gloucester children’s unit.

The range of services provided within the children’s unitincludes; oncology, surgery, medicine, neonatal intensivecare, physiotherapy and support services such as play andeducation. There are 52 beds which include:

• 29 general beds, which were arranged as onesix-bedded bay, two double-bedded bays and 19individual cubicles.

• One four-bed oncology unit• One four-bed high dependency unit.• An area of eight beds for children undergoing

procedures as a day-case• One seven-bed paediatric admissions unit (PAU).

There was also a neonatal intensive care unit with 28 cotsfor babies needing high dependency or short-termintensive care.

A team of clinical nurse specialists is based on thechildren’s unit and provides an outreach service across thecounty for patients with cystic fibrosis, asthma, diabetes,endocrine and dermatological conditions.

Children’s and young people’s outpatient services arelocated in the children’s unit and at Cheltenham GeneralHospital, although some of these patients may be seen inthe general outpatients department depending on theconsultant they are seeing. Some consultants provideservices for children in the community and see patients atcommunity hospitals and schools that provide educationfor children with additional needs.

We spoke with eight parents and observed care of threechildren and young people during our inspection. Wespoke with 26 staff, including nurses, consultants, medicalstaff, managers and support staff. We visited all the areaswithin the children’s unit. We observed care and looked at12 patient records and other documents provided by thetrust. Before and during this inspection we reviewedGloucestershire Hospitals NHS Trust performanceinformation.


Servicesforchildrenandyoungpeople

Services for children and young people


Summary of findingsThis was a focussed inspection to follow-up on concernsfrom a previous inspection. Our inspection team onlyinspected the safe domain. The trust’s previous CQCinspection was in March 2015. At this inspection safetyfor patients attending the children’s service was rated asrequiring improvement. This was because there wereconcerns about the medical cover for middle gradedoctors on both the neonatal and children’s units andthe lack of staff available to deal with safeguardingreferrals in a timely way.

During this inspection we rated safe as good because:

• There was an open reporting culture by staff whoworked in the children’s services. This helped tomaintain the safety of treatment and care for babies,children and young people.

• There was evidence to show incidents, concerns ortrends were investigated for learning opportunitiesand actions taken to improve practice.

• Staff understood their roles and responsibilities tosafeguard children from potential risks or abuse andreceived supervision on a regular basis. The trust’ssafeguarding teams worked with community andsocial care colleagues to identify and supportchildren who may be at risk.

• Systems for staff shift handovers promoted the safetyof children. Staff were fully included in processes andencouraged to contribute.

• Records showed electrical and mechanicalequipment was regularly maintained to ensure it wassafe to use and review dates were clearly indicated.

• Risk assessments were used with all children toidentify the level of care they needed. These wereaudited regularly to check they had been completedcorrectly and concerns had been escalated forfurther advice where necessary.

• Staffing levels were regularly reviewed and plannedto follow national guidelines and standards.However, staffing levels had been challenged withunexpected staff absences. Managers were takingsteps to fill gaps in the short term, recruit staff on apermanent basis and maintain staffing levels.

However:

• Compliance with audit processes for infectionprevention and control was variable across thechildren’s services and had not been consistentlycompleted.

• Routine stock checks of some medicines were notalways completed according to the trust protocol.




Are services for children and youngpeople safe?

Good –––

During this inspection we rated safe as good because:

• There was an open reporting culture in the children’sservices which helped to maintain the safety for babies,children and young people. Any incidents, concerns ortrends were investigated for learning opportunities andactions taken to improve practice.

• Safeguarding practices were good and continued toimprove, with communication between departmentsbeing encouraged. Staff understood their role insafeguarding children and received supervision on aregular basis. Safeguarding teams worked withcommunity and social care colleagues to identify andsupport children who may be at risk.

• Systems for handovers of patient care protected thesafety of children. Staff were fully included in theprocess and encouraged to contribute.

• Electrical and mechanical equipment was regularlymaintained to ensure it was safe to use and review dateswere clearly indicated.

• Risk assessments were used for all children to identifythe level of care they needed. These were auditedregularly to check they were completed correctly andconcerns had been escalated for further advice wherenecessary.

However:

• Compliance with audit processes for infectionprevention and control was variable across thechildren’s services. Audit results were not alwayscompleted by children’s services.

• Routine stock checks of some medicines were notalways completed according to the trust protocol.

• Not all outpatient waiting areas in the hospital hadspecific children’s areas. This meant there was apotential safeguarding risk for children who may beunsupervised by parents, guardians or hospital staff.Areas that were not solely for children’s use in otherparts of the hospital had waiting areas that were sharedwith adults.

Incidents

• Children’s services’ staff demonstrated understanding ofwhat types of issues to report and how to do this. Theyused investigations from incidents to improve safety forchildren, young people and their families. Seniormanagers for children’s services monitored andreported any incidents in accordance with the SeriousIncident Framework 2015.

• The children’s service reported no incidents which wereclassified as never events for the reporting period ofDecember 2015 and November 2016. Never events areserious patient safety incidents that should not happenif healthcare providers follow national guidance on howto prevent them. Each never event type has thepotential to cause serious patient harm or death butneither need have happened for an incident to be anever event.

• The trust reported one serious incident betweenDecember 2015 and November 2016 in children’sservices, which met the reporting criteria set by NHSEngland. This was regarding risk assessments that hadnot been well completed for a child whose conditiondeteriorated. Records showed this was investigated andlearning from the incident was shared with staff toprevent a reoccurrence. This included changes toprocesses by ensuring prescribers had quiet space tocomplete prescriptions and reminding staff to checkrecords for any allergies.

• There was a strong culture of identifying and reportingany risks to improve safety for children and youngpeople. Staff followed the trust policy for raisingconcerns about safety incidents and near misses. Theyused an electronic system and received feedbackregarding progress of any investigation.

• Minor incidents were followed up by the ward managerand more serious concerns were escalated to the riskand safety manager for further investigation.Multi-disciplinary risk meetings would be held todiscuss solutions and any changes in practice toimprove the service. Records showed they included anystaff involved in the incident as well as senior managers.As an example, an incident involving the out of hoursservice had prompted paediatric staff to contribute toimproving public information about how and when touse out-of-hours and emergency services for children.

Duty of Candour

• Regulation 20 of the Health and Social Care Act 2008(Regulated Activities) Regulations 2014 is a regulation




which was introduced in November 2014. ThisRegulation requires the trust to be open andtransparent with a patient when things go wrong inrelation to their care and the patient suffers harm orcould suffer harm which falls into defined thresholds.We saw how this was implemented following a drugerror incident. Parents had received an apology in atimely way with an explanation of the possible effectsand actions needed for their child.

Mortality and Morbidity

• Staff from the neonatal unit attended monthly mortalityand morbidity meetings for their department. Duringthese meetings any neonatal deaths and severe medicalconditions were reviewed to identify where actionsmight improve outcomes for babies. Records showedthese meetings were attended by a range of seniorclinicians and nursing staff and learning was shared.

• A paediatrician from the children’s unit discussed childdeaths at multi agency child death and overview panelmeetings, which were held every two months. Actionpoints for improvement were identified and allocated toa named person and monitored for completion atsubsequent meetings. Information was shared with staffat team meetings.

Safety Thermometer

• The children’s unit had been monitoring the safety ofcare provided by contributing to the NHS safetythermometer since September 2016. The NHS safetythermometer is a local improvement tool for measuring,monitoring and analysing patient harm and ‘harm free’care on a set day every month. It provides informationon a ‘snapshot’ in time. For children this includedmonitoring paediatric early warning scores, infectionsfollowing intravenous therapy, pain assessments andany moisture lesions related to a device such asnasogastric tube.

• Ward managers had made a decision that four monthsof data was not sufficient to give valid information ontrends of care and planned to review the results in June2017. However, they were monitoring the results andstaff received feedback individually on the results of thismonthly audit

• Safety thermometer information was displayed on theward for staff, visitors and patients to see.


• The trust had policies for infection prevention andcontrol which followed national guidelines.

• Staff on the children’s unit were pro-active in identifyingand acting on risks for infection prevention and control.However, compliance with audits was variable acrossthe children’s and neonatal unit. In January 2016children’s unit staff had investigated reasons for theincidence of a small cluster of infections in children whohad central lines in place. This had resulted in ensuringthat training provided for staff was relevant and thatstaff had accessed training in aseptic non-touchtechniques.

• There were no reported incidents of health careassociated infection for the children’s service betweenJune and October 2016.

• Staff compliance with trust policies on basic techniquesfor hand hygiene and the care of peripheral venouscannulas were audited monthly and results were ratedeach quarter as red, amber or green. Anything below100% was considered to be a risk. On the children’s unit,care of peripheral venous cannulas ranged from 70%compliance in April 2016 to 90% in October 2016.

• Staff compliance with hand hygiene techniques wasbetween 80% and 100%. The neonatal unit showed100% compliance with hand hygiene for the sameperiod but had not returned any audits on the othermeasures. This meant no judgement could be formedon what actions staff were taking to protect babies frominfection. Audit results and action plans were reportedto the Women’s and Children’s directorate quality groupevery three months for review.

• All staff we observed carried out appropriate handwashing practises and ensured visitors followed thesame protocol.

• Hand cleansing gel was available in all entry areaschildren attended with instructions for how to use thegel.

• The children’s unit and the neonatal unit had individualrooms that could be used to nurse patients and protectthem and others from an infectious condition.

• We saw staff using personal protective equipment suchas aprons and gloves. These were in plentiful supply andeasily accessible.

• All the areas we visited were clutter free and equipmentlooked clean. A member of nursing staff used a templateto audit environment and equipment each month.Records showed actions that were required to maintaingood infection prevention and control measures.




• Reusable “I am clean” labels were used to indicatewhich equipment had been cleaned and was availablefor further use. The November audit on the children’sunit had identified that “I am clean” labels were notbeing used consistently. Actions were to remind staffabout correct use of labels and the January auditshowed an improvement. We saw these labels usedappropriately on multi-use equipment.

• Staff ensured toys were cleaned regularly and we sawrecords documenting this. Nursing staff placedcontaminated toys in a protective bag and playspecialists used the appropriate cleaning method whichfollowed trust protocol.


• The environment and equipment used by the children’sand neonatal unit were maintained in a way thatreduced risks to patient safety. Ward areas on thechildren’s unit and neonatal unit were spacious enoughto allow staff to attend to patient’s needs withoutcausing an obstruction. Equipment was placed instorage cupboards when not in use.

• The children’s unit had two rooms which had beenadapted to provide sensory distractions. This was usedfor children living with conditions such as autism,behavioural and sensory disorders. This included colourchanging water tubes and soft music.

• Some individual rooms could be easily adapted tomaintain safety for children and young people withemotional health needs. Adaptations included a screenthat eradicated ligature risks and access to oxygen/suction equipment, and making bathrooms accessibleto staff whilst maintaining patient privacy.

• Areas that might have been a risk to children, such askitchens and storage rooms, either had locked doors orhad a barrier which prevented young children fromaccessing them.

• The operating department had a recovery area that keptchildren and adults separate, which met nationalguidelines for the care of children undergoinganaesthesia.

• Secure external areas were available for children to play,overlooked by the ward areas which helped to maintainsafety.

• In the children’s recovery area, children’s unit andneonatal unit, resuscitation equipment was available forall ages and accessible for staff. We saw records whichshowed staff documented equipment had been

checked as safe and available to use. We saw oneresuscitation trolley that had not been checked for anumber or days and this was brought to the attention ofward staff.

• The trolleys used to store the emergency equipmentwere covered with a cloth screen which would not showevidence of tampering. Staff followed a policy ofreplacing any equipment that had been used but otherpeople could remove items without staff knowledge.This caused a potential risk of equipment beingunavailable in an emergency situation.

• Staff undertook a monthly health and safety audit whichincluded waste management and the state of repair ofany fixtures, fittings and equipment. Any repairs neededwere requested from the appropriate department andprogress on completion was monitored at the nextaudit.

• Storage of items for disposal was appropriatelymanaged at the time of our visit and items were keptout of the reach of children.

• All electrical equipment we saw had been maintainedappropriately and had labels documenting when it wasnext due for a service.

Medicines

• Arrangements were in place for the safe management ofmedicines and medical gases which met nationalstandards.

• Children’s weights and known allergies were clearlydocumented on children’s and babies’ medicine chartsfor staff to review when prescribing medicines. Heightswere recorded in the medical record if the child’smedical condition made this possible but we did notsee any heights recorded on the medicine charts wereviewed.

• Audits showed that staff compliance with trust policieswas inconsistent on the children’s unit. For example,refrigerator temperatures were not always checked(57% - 100% compliance), treatment room doors werenot always locked (25% - 100% compliance) andmedicines were sometimes left out in treatment rooms(50% - 75% compliance). The neonatal unit areas ofnon-compliance for the same period were for medicinesleft out (0% -100%), and medicine refrigerators notlocked (0%), although these refrigerators were situatedwithin the nurseries where staff were present. Thisinformation was shared with ward managers whoreminded staff about actions they needed to take to




follow the trust policy. Records showed the children’sunit continued to monitor these actions in their monthlyhealth and safety audit of the children’s and neonatalunits. At the time of our visit we saw refrigeratortemperatures had been documented as checked dailyand protocols for reporting temperatures outside ofaccepted levels were attached. Doors were lockedappropriately and no medicines were left out ofcupboards unattended.

• Staff followed the trust policy of checking thatcontrolled drugs were checked by two registeredmembers of staff each time they were used. They alsochecked the stock of these medicines every 24 hours asan additional safety check. However, on the children’sunit records showed five occasions during January 2017when these stock checks had not been documented ascompleted. The neonatal unit checked stocks ofcontrolled drugs three times daily using two registerednurses. And we saw these had been completed.

• Pharmacy staff provided support to the children’s andneonatal units by visiting the ward daily betweenMonday and Friday. Pharmacy staff were responsible forreplenishing stocks and reviewing medicine charts forappropriate prescribing.

• Any errors found in medicine prescribing oradministration were reported using the trust incidentreporting system. The children’s unit managers receivedfeedback on each incident. They had found an increasein the incidence of medicine errors and investigatedpotential causes. Changes in practice following thisinvestigation included measures to protect staff fromdistraction when prescribing and administeringmedicines. We saw staff wearing ‘do not disturb’ tabardswhen administering medicines to enable staff toconcentrate on medicines and reduce the risk of errors.Staff were encouraged to use a quiet area of the wardwhen prescribing.

• Some nursing staff had additional competencies andfollowed trust documents which allowed them toprovide commonly available medicines for children andyoung people. These were called patient groupdirections and we saw five that needed to be updated.Staff told us and managers confirmed that these were inthe process of being reviewed by the pharmacy director.

• Each emergency trolley we looked at had tamperevident emergency medicine boxes. There was a quickcalculation reference document attached for theadministration of emergency medicines to children. Thiswas written in accordance with national guidelines.

Records

• Patient records were written in a way that kept childrenand young people safe and were kept securely introlleys by nursing stations. All records for patients onthe children’s unit were accessible for staff.

• Paper records were kept for each patient and wereupdated by professionals involved in the child’s care. Aseparate nursing folder held assessment charts of achild’s condition such as temperature, heart rate, bloodpressure, and skin and pain assessment. These wereregularly reviewed by nursing staff.

• A daily audit of five records was carried out by the wardco-ordinator. Included in the audit was whether riskassessments had been completed accurately, entries tomedical records were signed and dated and whetherfluid charts were totalled for the previous 24 hours. Anydiscrepancies were fed back to staff at the time of theaudit.

• We reviewed 12 sets of patient care records and sawthey were clearly written, signed and dated by thehealth professional who had seen the child. It includedspecialist advice from other professionals such asspeech and language therapists. This allowedpractitioners to review changes in the child’s conditionand treatment using up-to-date information.

• Staff were informed of any safeguarding concernsregarding a child being admitted to the unit. Both paperand electronic records had alerts which clearlyhighlighted if there were any safeguarding concerns.

• We saw each patient’s GP was informed of a child’s careneeds when they were discharged from hospital.Duplicates of letters sent to GPs were stored in eachpatient’s care file. GPs were also able to refer children into the paediatric assessment unit and letters were keptin the patient record.

Safeguarding

• The trust had policies to identify and act onsafeguarding children concerns which followed nationalguidelines. Staff we spoke with about safeguardingchildren were aware of their responsibilities and whatprocesses to follow.




• The trust team for safeguarding children included leadsfrom the executive team, a non-executive director andsenior medical and children’s nursing teams. The teamworked closely with the local safeguarding children’sboard and the clinical commissioning group’sdesignated doctor for safeguarding children. The teamattended a range of meetings with partner agenciessuch as community and social services and the localsafeguarding children’s board to share best practice andpromote a consistent approach.

• The trust safeguarding team were in the process offorming links with similar organisations in the southwest region to provide peer support. We saw updatesand information was cascaded to staff throughdepartmental and team meetings and the vulnerablewomen’s safeguarding forum.

• The women’s safeguarding team had been recentlyformed and included staff from midwifery, substancemisuse, teenage pregnancy and neonatal services. Theteam met monthly and shared information on risks forbabies on the neonatal unit.

• Systems were in place to process safeguarding referralsand were provided 24 hours a day, seven days a week bystaff within children’s services. Advice was available fortrust staff and outside agencies such as police andsocial care. Community paediatricians were availableduring the day and paediatric consultants wereavailable in the evenings and on call after 10pm.Concerns had been raised at the previous CQCinspection about a waiting list of children who wererequiring a child protection medical examination. Thesafeguarding leads were clear that all children needing amedical examination were seen on the same day as thereferral and there was no waiting list.

• Reports were presented to the trust quality andperformance committee every three months andannually to the trust board of directors. These reportsincluded safeguarding children activity, staff trainingand national developments.

• Staff were supported with child protection andsafeguarding concerns with regular supervisionopportunities by staff who had undertaken additionaltraining in safeguarding children and supervision ofstaff. This included combined group supervision fornurses and doctors and individual support if staffrequested it. Learning from local and national seriouscase reviews was shared during the supervision

sessions. Learning from case reviews had promptedother safety information being developed. For example,information was developed and provided for newparents on how to deal with a crying baby in order toprevent parents shaking their babies.

• All staff we spoke with knew who to contact if theyneeded advice regarding safeguarding children issues.Any issues of concern for babies being discharged werereported to staff in community services. This hadincluded a recent case related to female genitalmutilation.

• The trust worked in partnership with the localcommunity service provider to provide termination ofpregnancy. If a pregnant child under 13 years of ageattended staff would follow safeguarding procedures toprotect the child from potential abuse.

• Some children and young people were seen inoutpatients departments in other areas of the hospital.There were occasions when they shared waiting areaswith adults which could create a potential safeguardingrisk if parents were not present. We saw records of howa safeguarding concern had been raised by staff in thegeneral outpatients and had resulted in positiveoutcomes for the child.

• Tools and guidance were available for staff if they wereconcerned about domestic abuse. This included a quickreference guide and a more detailed check list.

• The neonatal unit followed the trust abduction policyand operated a tagging system to prevent babies frombeing taken from the unit without authorisation. Anyunauthorised removal of a baby would sound alarmsand lock doors. This system could be overridden by staffon the unit if there were safety reasons to open thedoors. Visitors to the neonatal unit needed to be let in orout by staff and were monitored using closed circuittelevision. Visitors to the paediatric unit were let in bystaff and could exit using a door release place too highfor young children to access.

Mandatory training

• Training programmes were provided for staff to attendon a mandatory basis to ensure they were up-to-datewith processes to maintain safety for children, youngpeople and their visitors. This was started onemployment as an induction programme andcontinued with regular updates.

• The trust monitored staff attendance at 12 modules andhad set a target of 90% attendance. The children’s




service met this target for one module, equality anddiversity awareness, for the medical staff group. Theremaining 11 modules had compliance rates between79.4% (manual handling practical) and 88.2% (manualhandling theory).

• The children’s service nursing staff group met theircompliance target for all but two of the 12 modules. Thetwo modules that were not met were basic adultresuscitation (89.3%) and conflict resolution (72.7%).Plans had been put in place to address this, includingadditional training days during 2017. Planned trainingincluded subjects specifically relevant to children andyoung people such as; mental health, management ofdiabetes and the deteriorating patient.

• Children’s service staff had training in paediatric lifesupport and safeguarding children’s training modules toattend which were in line with national statutoryguidance. The trust met their 90% target for medicalstaff in three of the four modules, level two safeguardingadults being the only module below the target. Nursingstaff met the 90% target in all four modules. Staff inother departments had safeguarding training, such asthe radiology department. This was used by adults andchildren and had two radiographers who had level threechildren’s safeguarding training.

• Staff were trained to respond to emergency situationsfor children of all ages. The majority of neonatal staff(94%) were trained in new born life support. Thechildren’s unit had 13 new members of nursing staff and79% of the team had attended paediatric life supporttraining. Another 16% were booked on to courses.Advanced paediatric life support had been attended by53% of nursing staff.


• The trust followed national guidelines to ensure thatpotential risks to patient safety could be assessed andresponded to appropriately. Staff were trained to useassessment tools which supported their professionalknowledge and skills.

• Risk assessments completed for patients werecomprehensive and action plans reviewed. Nursing staffon the children’s unit used paediatric early warningscore (PEWS) charts to monitor a child’s condition. Thisrecorded observations of temperature, heart rate,respiration rate and blood pressure measurements.Guidance was included for staff to follow if a child’s

condition deteriorated. We saw records of children whohad undergone surgical procedures who had beenassessed for their risk of developing venousthromboembolism.

• Staff compliance with completing the PEWS charts wasmonitored daily. The ward co-ordinator completed anaudit form and fed back findings to staff at the time ofaudit. The ward coordinator had found the daily auditdifficult to complete when workload was high and wereplanning to share the task with other nursing staff.

• The rate of compliance with PEWS was reported to thenational patient safety thermometer on a monthly basis.In September 2016 one occasion of a child’sdeteriorating condition had not been escalatedappropriately and staff had been reminded of correctescalation procedures. Following this audit, results wesaw for September 2016 had shown 100% compliance.The children’s unit also used a newly produced sepsisscreening and action tool which included a flow chart toguide staff on appropriate actions.

• The neonatal unit had completed trials of acomprehensive risk assessment booklet to be used foreach baby in the unit. It included assessment tools forskin ulceration, pain and wound management and hadbeen used by staff in the unit for two months

• Staff followed the trust policy for any child who wasseriously unwell and needed to be transferred to a morespecialist hospital. This included detail on how tocommunicate with transport organisations, staff at thereceiving unit and what level of staff would be neededto accompany the child.

• Theatre and recovery staff who had paediatricexperience and were trained in paediatric life supportcared for children and young people post-operatively.This met national guidelines for the care of the childimmediately after anaesthesia.

• The children’s and neonatal unit had a member of staffon duty at all times, who had advanced life supporttraining appropriate for the age of children being caredfor.

• Children who attended the hospital due to emotionalissues were assessed for their risk of self-harming. Thelocal mental health trust provided support for staff andwould provide additional support for a child who was aninpatient on the children’s unit. This was done tomaintain the child’s safety.




• Staff used the World Health Organisation checklist forsafer surgery appropriately. Each member of thesurgical team was engaged with the process.

• Parents told us they felt their child was safely cared foron the children’s unit. The paediatric assessment unitreviewed patients who had been referred by GPs or theemergency department. All referrals were discussedwith a paediatric consultant and patients could becared for on the ward, seen in follow up clinics ordischarged home. Parents of children who attended thepaediatric assessment unit received a phone call theday after their attendance to check on their child’scondition. Parents told us they found this reassuring.

Nursing staffing

• Recruiting to substantive posts and maintaining nursingstaffing levels had been a concern for ward managers.However, staffing rotas showed levels were appropriatefor the children’s and neonatal units and followednational guidelines including the 2013 Royal College ofNursing and the British Association of PerinatalMedicine (BAPM). The children’s unit arranged nursestaffing to patient ratios of one registered nurse for fourpatients and increased staffing if there were childrenunder the age of two years, or patients needed highdependency care. This was only achieved by usingadditional bank staff because there were not enoughsubstantive posts in place at the time of our visit.However, children’s service managers had reviewed anddeveloped a workforce plan in order to improve andmaintain the recommended staffing levels. This planidentified where shortfalls were and methods ofrecruiting registered nursing staff. This had includedrecruiting internationally, recruiting nursing staff whowere about to complete their training and havingpaediatric nursing jobs advertised on a rolling basis. Notall of the newly recruited nursing staff had started workon the children’s unit and this left some gaps in the rota.These could be filled with existing staff workingadditional hours, bank and agency staff. Financialincentives were offered to existing staff to fill the gapswhich staff felt provided more efficient workingarrangements and continuity for the patient.

• Established staffing figures for the children’s unit metthe recommended guideline proportion of 70%

registered to 30% unregistered nursing staff. Nursingstaff worked flexibly across all areas of the children’sunit. Staff rotas showed the appropriate numbers ofstaff on duty in each area.

• A senior member of staff was allocated the role ofco-ordinator for each shift and was available to offeradvice for less experienced nursing staff. Managers toldus difficulties arose when there were more than twopatients in the high dependency unit.

• The neonatal unit followed BAPM guidelines and staffedthe unit accordingly with one registered nurse for everyfour babies in special care, and one registered nurse forevery two babies requiring high dependency care. Theunit were very close to meeting the BAPMrecommendation that 70% of nursing staff on theneonatal unit had accessed additional training and werequalified in their specialty. There were 68% of nursingstaff who were qualified in their specialty and anothernurse was due to complete their additional training.

• Nursing handovers included a safety brief update. Thisincluded an overview of patients’ needs, those due foradmission, discharge and staffing numbers for the shift.A senior nurse who had attended the medical handoverensured that information was shared with nursing staffat this time.

Medical staffing

• Our previous inspection identified concerns regardingthe number of doctors available to safely cover thepaediatric and neonatal unit. A medical workforceplanning group had been identifying ways to cover therotas and increase numbers of doctors. They hadachieved a full establishment of medical staff for sixmonths until individual events, such as maternity leave,had created gaps. There were plans to interview aspecialist grade registrar in the near future to fill one ofthe posts available. Since the previous inspection twoadvanced neonatal nurse practitioners (ANNP) hadcompleted their additional training which allowed themto take part in the medical rota for the neonatal unit.This meant there were two experienced ANNPs whocould support the rota at middle grade level and twoANNPs who would be able to support the rota from ajunior medical grade level.

• Paediatric areas were safely staffed by doctors withadvice available from experienced paediatricians. This




had been achieved by rearranging the hours consultantswere present at the hospital and using consultants towork as a middle grade doctor when there were gaps inthe rota.

• Throughout August 2016 the proportion of consultantstaff reported to be working at the trust was higher thanthe England average, and the proportion of junior(foundation year 1-2) staff was about the same as theEngland average.

• Doctors who were more junior to consultants were ableto access support from consultant paediatricians at alltimes. A consultant was present for each paediatric areaduring times of peak activity. Between 9am and 10pm aconsultant was present for the paediatric admissionsunit and inpatient ward. For the neonatal unit therewere two consultants available from 9am until 5pm.After 10pm middle grade doctors were present in thehospital and supported by consultants who were off-sitebut on-call.

• Any gaps in the medical rota that could not be filled by alocum doctor were fulfilled by consultants who would‘act down’ to ensure medical cover remained at safelevels for patients.

• Staff shift handovers were held twice daily, led by aconsultant paediatrician and attended by a member ofnursing staff. We saw these were facilitated to encouragestaff to contribute to discussions and were used aslearning opportunities for medical trainees. Safetybriefings were included in the handover and socialissues and safeguarding concerns were discussed as apriority.

• The requirements to provide a medical review ofpatients met national standards for paediatric care.

Records confirmed each patient had been seen by amiddle grade health professional and a consultant in atimely way. Consultants followed best practiceguidelines and operated a system of ‘hot weeks’ whenthey were the admitting consultant for that week. Eachchild had a review of their medical needs before theywere discharged.


• The effects of winter pressures on the paediatric servicewere discussed regularly at the senior paediatric nurses’meetings. Ward managers described actions they wouldtake to meet increased service demands. This includedassessing patients who could be discharged andspeeding up the process of obtaining medicines to takehome by contacting pharmacy when there was higherdemand. Children’s services had beds and cot spacesthey could use flexibly depending on the needs of thebabies and children. The neonatal unit could increasetheir cot spaces from 28 to accommodate 32 babies.Paediatric day case beds could be used to increasenumbers of beds for overnight stays on the children’sunit by using the eight day-case unit beds.

• Staff were aware of emergency procedures such asevacuation for fire and action cards that described theroles of each member of staff were displayed.

• If a crisis situation in the hospital increased demand forregistered children’s nurses, a bank of nurses could becontacted and with manager’s approval agencies couldbe approached to provide additional registeredchildren’s nurses.




Safe Good –––



Responsive Good –––

Well-led Good –––

Overall Good –––

Information about the serviceEnd of life care included all care given to patients who wereapproaching the end of their life and following death. Thiscould be provided on any ward or within any service in thetrust and was provided by a range of staff. It includedessential nursing care, specialist palliative care, andbereavement support and mortuary services.

The trust’s specialist services for end of life care wereprovided through two teams who were managed through adivisional structure that covered both of the hospitalswithin the trust. Some staff worked at both sites ofGloucestershire Royal Hospital and Cheltenham GeneralHospital. End of life care followed trust policy at both sitesso similarities between the content of the two end of lifecare location reports occur in both hospital locationreports.

The in-patient and community specialist palliative careteam delivered a face to face service from 9am to 5pm,Monday to Friday. There was an out-of-hours telephoneadvice line available 24/7 for health care professionals.

The two end of life teams provided support and advice forany adult patients throughout the hospital or at therequest of clinical staff identified with complex care and/orcomplex symptom management. Support was alsoprovided to relatives of end of life patients. The in-patientand community teams provided care for patientsdischarged from both hospitals.

The teams worked with two full time doctors one aconsultant in palliative medicine and the other a specialtydoctor in palliative medicine. Both teams worked with apsychologist

The team that provided specialist end of life care forin-patients for the trust consisted of five advanced nursepractitioners and four clinical nurse specialists. Two of thefive advanced nurse practitioners were based atGloucestershire Royal Hospital with one working acrossboth sites. Two advanced nurse practitioners worked withthe advanced nurse practitioners at Cheltenham generalHospital.

The community team consisted of three advanced nursepractitioners and twelve clinical nurse specialists based atGloucestershire Royal Hospital who provide end of life carefor patients discharged from both hospitals. The team thatprovided care for community patients discharged fromCheltenham General Hospital was based at GloucesterRoyal Hospital with additional work bases at three hospicesin the area.”

A social worker and an occupational therapist were part ofthe multidisciplinary team employed by the trust andworked with the specialist palliative care team.

This was a focused announced follow up inspection.Following the previous inspection in March 2015 end of lifeservices for the trust had been rated as requiresimprovement for safe, effective and for well-led. The trusthad been rated as good for caring and responsive.

As part of this inspection, CQC piloted an enhancedmethodology relating to the assessment of mental healthcare delivered in acute hospitals; the evidence gathered

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End of life care


using the additional questions, tested as part of this pilot,has not contributed toour aggregation of judgements forany rating within this inspection process. Whilst theevidence is not contributing to the ratings, we havereported on our findings in the report.

Summary of findingsWe rated this service as Good because:

• End of life care provided at Gloucestershire RoyalHospital was safe, effective caring, responsive andwell led because:

• The processes in place to keep people safe for end oflife care were good. Staff in the specialist palliativecare team and other areas understood theirresponsibilities to raise concerns, record safetyincidents and report them. Lessons were learned andimprovements were made when things went wrong.

• Patient’s records demonstrated that nutrition andhydration needs were assessed and appropriateactions were documented as followed in patients’individual care plans.

• Records documented discussions with relativesaround what to expect with the dying process.

• Risks to patient’s receiving care at end of life wereassessed by ward staff with appropriate assessmentsrecorded in medical records for example theprevention and management of pressure ulcers andfalls.

• Staff we spoke with on the wards understood thatend of life care could cover an extended period forexample in the last year of life and also applied topatients with non-cancer diagnoses such asdementia. Staff, teams and services worked togetherto deliver effective care and treatment.

• Staff we observed on wards and in the communitydelivering end of life care to patients were compliantwith key trust policies such as infection control.

• Arrangements in place for managing medicines keptpatients safe. Medicines to relieve pain and othersymptoms were available at all times. Wards hadadequate supplies of syringe drivers (devices fordelivering medicines continuously under the skin)and the medicines to be used with them.

• There were reliable systems, processes and practicesin place to keep patients safe and safeguarded fromabuse.

• The staffing levels and skill mix of the nurse andmedical personnel in the specialist palliative careteam were planned and reviewed and supportedsafe practice. We saw evidence of a yearly education

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programme of end of life care for medical, nursingand allied health professionals. This included:resuscitation, syringe driver training, quarterly end oflife study days and symptom management.

• The specialist palliative care team respondedpromptly to referrals, usually within one working day.

• Patients were treated with kindness, dignity, respectand compassion. Staff took the time to interact withpeople who received end of life care and those closeto them in a respectful and considerate manner.

• We saw many written compliments about how caringstaff were in the inpatient and community end of lifecare teams. We saw that patients’ and those peopleclose to them, were involved as partners in their care.

• The specialist palliative care team and wards staffunderstood the impact a patients’ care, treatment orcondition had on their wellbeing and on thosepeople close to them.

• Emotional support for patients and relatives wasavailable through the in-patient and community endof life care team, the chaplaincy team andbereavement services. Staff had access to supportthrough their own teams when needed.

• Services were delivered and additional servicesplanned in order to effectively meet patient’s needs.Plans and actions included audit to inform futureplanning so that the end of life team could informbetter decision making with patients they cared for

• The bereavement office was one of two sites in thecountry involved in a pilot project to improve deathcertification which was more supportive to bereavedrelatives and provided better oversight of causes ofdeath.

• There was a clear vision and strategy to deliver careat end of life. The governance framework for end oflife care ensured that responsibilities were clear andthat quality, performance and risks were understoodand managed.

• Leadership encouraged openness and transparencyand promoted good quality care. There were leadson the wards that supported the development anddelivery of high quality end of life care.

• Services within specialist palliative and end of lifecare had been continuously improved andsustainability supported since the last inspectionMarch 2015.

However:

• Documenting ‘Do Not Attempt Cardio-PulmonaryResuscitation’ (DNACPR) decisions had improvedsince the last inspection however concerns regardingDNACPR remained. For example not all DNACPRhaving relevant clinical information and not allpatients or those close to them being recorded asinvolved in discussions about resuscitation. Theseconcerns were not identified as a risk and did notfeature on a risk register

• There were no centrally held training records forsyringe driver training or competency for ward staff.

• There was not a full understanding of performancefor all aspects of end of life care. For example thepercentage of patients dying in their preferredlocation and the percentage of patients dischargedwithin 24 hours were not known for all wards orhospital sites.

• There was no risk register specific to end of life carefor the trust so oversight of all end of life risk was noteasy.

• When we reviewed maintenance records someprovided were out of date. The trust told us theywere clear that equipment listed was not in use. Wesaw email communication from directors supportingthis.

• There was not a seven day face to face serviceprovided by the in-patient and community end of lifecare team. The trust provided a face to face service9-5 Monday to Friday. Out-of-hours there was atelephone advice line available 24 hours, 7 days aweek for health care professionals to access.

• Some of the ‘white rose’ symbols used to locate themortuary at the hospital were not easy to follow.Signs were not always at eye level for someonewalking or in a wheelchair and there were long gapsin signage that led to confusion. Mortuary andbereavement officers told us relatives hadcommented they were useful. Some relatives hadreported they appreciated these signs. Howeverbereavement office staff accompanied relativeswhen they knew people were attending themortuary.

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Are end of life care services safe?

Good –––

Overall we have rated safe as good because:

• There were processes in place to keep people safewhilst in receipt of end of life care. Staff in the end of lifecare team and other areas understood theirresponsibilities to raise concerns, record safety incidentsand report them. Lessons were learned andimprovements were made when things went wrong

• During the inspection we visited six wards wherepatients were receiving care in their last year of life.Compliance with relevant trust policies was good.

• The maintenance of equipment was compliant withpolicy and promoted safe patient care.

• Arrangements for managing medicines kept patientssafe. Guidance for staff on end of life medicines wasincluded as part of patients’ care plans which supportedthe management of a range of end of life symptoms.

• Potential risks to patients were assessed by ward staff.Identified patient safety risks were monitored andmaintained.

• There were reliable systems, processes and practices inplace to keep patients safe and safeguarded fromabuse.

• The staffing levels and skill mix of the nursing, medicaland other staff in the specialist palliative care team wereplanned and reviewed which supported safe practice.The nursing complement was complete for bothinpatient and community teams.

However:

• The completion of 19 do not attempt cardio pulmonaryresuscitation (DNACPR) forms we reviewed were ofvariable quality.

• There were no centrally held training records for syringedriver training or competency for ward staff.

• Some maintenance records provided were out of datealthough trust directors provided us with assurance viaemail that the equipment was not in use.

• The end of life team were unable to use the results ofthe safety thermometer specifically in relation topatients receiving end of life care as it was not possibleto sort data for all patients who might be in their lastyear of life.

• There was a trust major incident and businesscontinuity plan. However, the chaplaincy service,mortuary staff, bereavement officers and in-patient andcommunity palliative care teams had not been involvedin the major incident plan practice exercises.

• Though a system of ‘white rose’ signs were in place tosignpost people to the mortuary, they were not all easyto follow.

Incidents

• There were processes in place to keep people safewhilst in receipt of end of life care. Staff in the end of lifecare team and other areas understood theirresponsibilities to raise concerns, record safety incidentsand report them. Lessons were learned andimprovements were made when things went wrong Forexample: learning from incidents August to October2016 was incorporated in a recent end of life carepresentation which included learning related tomedications for patients to take home andimprovements in ward care for patients transferred tothe mortuary.

• The specialist palliative care team discussed relevantincidents and planned actions during regular meetings.Actions taken were recorded when they had beencompleted. Information and actions were shared duringstaff one to one meetings or via email updates. Staffsaid this ensured feedback and learning was shared andunderstood by the whole team. Issues were escalatedwhen required to the quality and performancecommittee.

• Between December 2015 and November 2016, therewere no incidents for end of life care reported whichwere classified as Never Events. Never events are seriouspatient safety incidents that should not happen ifhealthcare providers follow national guidance on howto prevent them. Each never event type has thepotential to cause serious patient harm or death butneither need have happened for an incident to be anever event.

• During this same period there were also no seriousincidents reported for end of life care. BetweenNovember 2015 and October 2016 the trust reported 82incidents related to end of life care. The two incidentcategories most commonly reported were medicinesnot ready for discharge 13 (16%) and pressure ulcers 11(13%). The trust also reported 28 mortuary incidentsfrom 24 January 2016 to 11 August 2016. Most mortuary

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incidents were related to not following care of the dyingpolicy. There had been 16 (19.5%) incidents atGloucestershire Royal Hospital. Actions had been takento reduce the risk of such incidents reoccurring.

Safety thermometer

• There was no palliative or end of life care ward at thehospital. We visited six wards at Gloucester RoyalHospital where patients where receiving care in theirlast year of life. All wards reported to the nationalpatient safety thermometer. This was used to record theprevalence of patient harm and to monitor wardperformance in delivering harm free care for wardswhere patients were receiving end of life care.Measurement on the wards was intended to focusattention on patient harm and prevention.

• Data collection took place one day each month. Datafrom the Patient Safety Thermometer showed that thetrust reported 123 pressure ulcers, 67 falls with harmand 67 urinary tract infections associated with urinarycatheter use between November 2015 and November2016.

• Results showed a reduction in pressure ulcer prevalenceand a decrease in falls.


• Staff were observed following trust policies. Forexample, staff were bare below the elbows, usedantibacterial hand gel between patient care, worepersonal protective equipment and disposed of wastecorrectly. This ensured that patients receiving end of lifecare who could be more susceptible to infection werecared for as safely as possible.

• Processes were followed by most staff which ensuredthat after death the health and safety of everyone thatcame into contact with the deceased patient’s body wasprotected. However, mortuary staff had recorded andreported occurrences where ‘last offices’ or the care ofthe deceased policy had not been fully followed. Thisincluded four instances where an infection risk or lastoffices policy had not been followed. Actions had beentaken to reinforce use of policy. For example reinforcing‘care of the dying policy’.

• Whilst the trust monitored the number of cases ofmethicillin resistant staphylococcus aureus (MRSA) andClostridium difficile (C’Diff) and methicillin-sensitivestaphylococcus aureus (MSSA) the number of casesattributed to end of life patients could not be identified.


• Processes were followed to safely maintain equipment.For example all syringe driver pumps in use weremaintained and used in accordance with manufacturesrecommendation.

• There were adequate numbers of syringe driversavailable to meet patient’s needs. There were noincidents raised about shortage of syringe drivers.

• The trust used one brand of syringe driver across allwards. This reduced the likelihood of confusion or errorby staff, particularly temporary (bank or agency) staff.

• We reviewed the maintenance records for syringedrivers. 17 out of 110 recorded syringe driversmaintenance records provided were out of date. Wenotified the trust who said that the units showing as outof date were not being used. An alert had already beenraised by the medical engineering department. The alertwas escalated to the district nursing leads across thecounty and also the nursing home support team toreinforce servicing of syringe drivers. The alert reinforcedthe system that supported safe management. All syringedrivers were managed by the medical equipmentlibraries. Staff removed any syringe driver from use if itwas identified as near to or past its service due date.

• The mortuary was difficult to find. The trust hadimplemented a system of ‘white rose’ symbols to assistlocation, however some of the signs were not easy tofollow. Signs were not always at eye level for someonewalking or in a wheelchair and there were long gaps insignage that led to difficulty in locating the mortuary.When we spoke with mortuary staff and bereavementofficers we were told that relatives had commented thesigns were useful, however they were accompanied tothe mortuary for viewings by staff so the signs were notrelied on.

• The mortuary viewing area was visibly tidy andappropriately located and furnished. The bereavementoffice was easily accessible.

• The chapel, the department of spiritual support,chaplain’s office and two multi-faith rooms were alleasily accessible, visibly clean and tidy.

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• The multi faith rooms consisted of two rooms whichwere separate from the hospital chapel. One room wasfor male use and one for female use. Both roomscontained ablution areas.

Medicines

• Processes were followed to safely manage medicines.Guidance for staff on end of life medicines was includedas part of patients’ care plans. Staff said this supportedthe assessment, management and review of a range ofend of life symptoms.

• Wards kept stocks of commonly used end of lifemedicines so they were available for prompt use.Records we reviewed showed that patients hadmedication provided when needed.

• In the records we reviewed we saw that patient’s needswere met with anticipatory medication being prescribedappropriately. Anticipatory medications aremedications prescribed ‘just in case’ or for whensymptoms known to occur at end of life are predicted tooccur. There was an anticipatory prescribing medicationchart available for use and linked to the trust’s sharedcare record for the expected last days of life. We saw thiswas used. The medicine chart was prepopulated withfive of the most common symptoms, and pain-relievingmedicines, with guidance for dose and frequency.

• We reviewed four sets of prescribing information fromfour wards - 7b, 7a, 6a and 9b. All records had beencompleted appropriately.

Records

• Most of the individual care records were written andmanaged in a way that kept patient’s safe. Recordscontained all relevant documentation, prescribinginformation, unwell patient forms or treatmentescalation plans and ‘do not attempt cardio pulmonaryresuscitation’ forms.

• We reviewed 23 sets of notes of patients who hadreceived end of life care. This included a review of fourmedication prescribing records and 19 do not attemptcardio pulmonary resuscitation (DNACPR) forms. Allwere stored securely. Discussions between clinical staffand patients and relatives were recorded legibly andsensitively.

• Patients’ records included advance care planning anddetailed conversations. These included explicit recordsof what patients and relatives understood or wanted to

be informed of, their concerns and wishes. Actions forstaff to take in accordance with these wishes and advicefor ward staff were clearly documented and reviewed bythe in-patient specialist palliative care team.

• All clinical staff we spoke with were familiar with thetrust’s shared care record for the expected last days oflife. The shared care record included risk assessments ofpatients’ nutrition, mobility and pressure area care. Thisdocument had been re-launched trust-wide duringJanuary 2015. The record provided prompts forclinicians which emphasised supporting patients’comfort and dignity. For example, in addition toguidance to manage pain and other symptoms, thedocument included actions to maintain mouth care andprovide spiritual support and space to record what hadbeen done

• However, we found variable quality in the completion ofdo not attempt cardio pulmonary resuscitation(DNACPR) forms. We looked at 19 and identified:

• There was a clearly documented decision withreasoning & clinical information in only 11 out of 19records (58%).

• Records also showed that the patient was not alwaysinvolved in discussions in seven out of 19 (37%) ofrecords.

• Discussions or the reasons why decisions had not beendiscussed had not been recorded on the DNACPR form.In 16 out of 19 (84.2%) records this had not beenrecorded in each patient’s health record with sufficientdetail

• However, completion of DNACPR had improved from thelast inspection in March 2015. We saw results from thelast two audits completed in both hospitals undertakenfollowing this. These showed an improvement incompliance with policy from between 46% and 64%compliance for the first audit. The trust achieved 75%compliance in December 2016.

Safeguarding

• There were reliable systems, processes and practices inplace to keep patients safe and safeguarded fromabuse. The specialist palliative care team and ward staffwe spoke were knowledgeable regarding processes tofollow if they had any vulnerable adult or children’ssafeguarding concerns. Staff were able to explain whatsigns might alert them to safeguarding issues, how toescalate these concerns and who to escalate them to.

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• Records showed that the majority of members of thespecialist palliative care team had in date mandatorysafeguarding vulnerable adults and safeguardingchildren training.

• The trust had set a target for all staff of 90% forcompletion of adult and children’s safeguardingtraining. The trust had met its target for medical staff forall four safeguarding modules at October 2016. Recordsshowed that between 93.2% and 90.1% of medical staffhad completed safeguarding training.

• The trust had met its target for nursing staffsafeguarding training for all but one of the foursafeguarding modules. Records showed that between94.4% and 93.8% of nursing staff had completedsafeguarding training. Level two safeguarding childrenfell just short at 89.8%

Mandatory training

• The trust had set a target for all mandatory training of90%. The specialist palliative care team, nurses anddoctors were not compliant with the trust target of 90%.

• The specialist palliative care team, nurses and doctorswere not fully compliant with all of these, however therewere now plans in place to address this shortfall nowthe team were at full establishment. Areas ofcompliance included Safety Awareness, Equality andDiversity Awareness, Basic Adult Resuscitation,Information Governance, Manual Handling Practical andConflict Resolution.

• However the team fell short of this target in BloodTransfusion (85%), Code of Conduct (88%), Fire (88%),Infection Control (88%), Manual Handling Theory (85%),Medicines Management (82%) and Prescribing (75%).


• Risks to patient’s receiving care at end of life wereassessed by ward staff, and their safety was monitoredand maintained.

• We reviewed 23 sets of patient records and saw riskassessments for nutrition, mobility including falls andpressure area care had been completed and riskmanagement plans had been developed. For examplewe saw patient’s mouth care had been assessed andactions put in place. In addition, medication had beenregularly reviewed in response to increased risks andchanges recorded.

• Staff identified and responded appropriately tochanging risks to patients who used services, including

deteriorating health and wellbeing. They used thenational early warning score (NEWS) to identify thedeteriorating patient and responded with increasedtreatment when appropriate. Community end of lifestaff also told of when NEWS might be inappropriate touse as part of the dying patient’s care.

Nursing staffing

• The staffing levels and skill mix of the nurses and otherstaff in the specialist palliative care team were reviewedand planned to support safe practice. The trust had anin-patient and a community specialist palliative careteam. The nursing complement was complete for bothinpatient and community teams and no bank or agencystaff had been used in the past year.

• Following recent investment the nurse team for theinpatient specialist palliative care team was provided by

• Five advanced nurse practitioners (band seven) and fourclinical nurse specialists (band six). Two advanced nursepractitioners were based at Gloucestershire RoyalHospital with one working across both of the trusthospital sites. Two clinical nurse specialists also workedwith the advanced nurse practitioners at the hospital.

• The team that provided care for community patientswas provided by

• Three advanced nurse practitioners (band seven) andtwelve clinical nurse specialists (band six) who werebased at the hospital. This team provided end of lifecare for patients discharged from both CheltenhamGeneral Hospital and Gloucestershire Royal Hospital.Clarified bullet. The team that provided care forcommunity patients discharged from CheltenhamGeneral Hospital was based at Gloucester Royal Hospitalwith additional work bases at three hospices in the area.

• Medical staffing• The staffing levels and skill mix of the medical staff in

the specialist palliative care team were planned andreviewed to meet patient needs. They did not useagency or locum staff.

• The trust employed one consultant in palliativemedicine full time. They covered both hospitals andworked with another full time specialty doctor inpalliative medicine. A community consultant inpalliative care was due to start 6 February 2017 whichwas a newly created post of 32 hours over four days(0.8WTE).

• Out of Hours cover was provided via telephone fromtrust and hospice consultants (weekend and nights)

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Other staff

• A social worker and an occupational therapist were partof the multidisciplinary team employed by the trust andworked with the specialist palliative care team.

• Chaplains were appointed by the trust to providespiritual, pastoral and religious care to the wholehospital whether a patient, a carer, or a member of staff.

• There were 141 chaplaincy volunteers that providedsupport across the trust in total (93 chaplaincy and 48Roman Catholic chaplaincy). All volunteers includingchaplaincy volunteers were Disclosure and BarringService compliant and checked. All volunteers hadcompleted a course to ensure they were competent toattend wards and support patients with spiritual andemotional issues.

• The chaplaincy volunteer service had received 12 longservice awards in 2016.


• There was a trust major incident and businesscontinuity plan. However the department for spiritualsupport, mortuary staff, bereavement officers orin-patient and community specialist palliative careteam for the trust had not been involved in a majorincident plan practice or exercise.

• However, staff we spoke with were aware of majorincident prompt cards to assist with processes and thetrusts policy. When we visited the chaplain’s office, wesaw major incident cards were visible on the walls.

• Risks to the provision of care was anticipated andplanned for in advance. The arrangements for theresponse to emergencies and major incidents bymortuary staff included the ability to transfer temporarymortuary storage between the two hospital sites.

Are end of life care services effective?

Good –––

We rated effective as good because:

• Staff we spoke with understood that end of life carecould cover an extended period for example in the lastyear of life or patients. They were also aware thatpatients benefited from early discussions and careplanning and this extended to patient groups withnon-cancer diagnoses such as dementia.

• The end of life care was delivered with the principles ofthe Priorities for Care of the Dying Person set out by theLeadership Alliance for the Care of Dying Patient’s

• There was a 35 point action plan created in response tothe trusts performance in the National Care of the Dyingaudit published March 2016. This included maintainingand where possible increasing education ofnon-specialist staff and repeating the national voicessurvey. Some actions had already been completed suchas appointing a non-executive to the board to representend of life, improved symptom control anddocumentation.

• Medicines to relieve pain and other symptoms wereavailable at all times. Wards had adequate supplies ofsyringe drivers (devices for delivering medicinescontinuously under the skin) and the medicines to beused with them.

• The patient’s records we reviewed demonstrated thatpatient’s nutrition and hydration needs were assessedand appropriate actions followed in patients’ individualcare plans. The records documented discussions withrelatives around what to expect with the dying process.

• The specialist palliative care team had worked towardsachieving improvements in patient outcomes andimprovements were seen in the 2015/16 National Careof the Dying Audit.

• There was a yearly programme of end of life careeducation for some medical staff which coveredsymptom management, levels of care, diagnosing dying,resuscitation and communication skills. There was alsosome evidence of a programme of non-medical staffeducation for nursing and allied health professionals forexample , covering resuscitation, syringe driver training,quarterly end of life study days and symptommanagement

• There was evidence of multidisciplinary working todeliver effective care and treatment.

However:

• Documentation relating to patients’ mental capacityand consent was not always complete or immediatelyobvious in ‘do not attempt cardio-pulmonaryresuscitation’ (DNA CPR) records.

• Explanations for the reason for the decision to withholdresuscitation attempts were not consistently clear.

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Records of resuscitation discussions with patients andtheir next of kin, or of why decisions to withholdresuscitation attempts had been made were not alwaysdocumented.

• There was no organisational oversight of staffcompetency with regards to syringe driver training asrecords were not held centrally.

• There was not a seven day face to face service providedby the in-patient and community specialist palliativecare team. The trust provided a face to face service 9-5Monday to Friday. Out-of-hours there was a telephoneadvice line available 24 hours, 7 days a week for healthcare professionals.

• Whilst in some cases the possibility of dying had beenrecognised and communicated clearly, decisions madeand actions taken in accordance with the person’sneeds and wishes, not all appropriate patientsexperienced this.

• Most local audit activity had yet to benefit from athorough analysis of the data produced. Despite thatthe in-patient and community specialist palliative careteam for the trust were acting on initial evidence fromaudit which supported national guidance and informedimprovement projects such as improving dischargeplanning arrangements.

• The learning needs of all staff delivering end of life carewere not identified.


• Patient’s needs were assessed and care and treatmentwas delivered in line with legislation, standards andevidence-based guidance.

• National Institute of Health and Care Excellenceguidance includes staff recognition of patients thoughtto be approaching the last year of life. We saw evidencethat staff understanding of this had increased since ourlast inspection. We saw patients who might beapproaching the last few days or hours of life receivingend of life care within the trust.

• Staff we spoke with on the wards understood that endof life care could include patients with non-cancerdiagnoses such as dementia. Staff understood patientscould benefit from discussions about their care andwishes early on in the end of life care pathway.

• The in-patient and community palliative care team inconjunction with the end of life quality group wereresponsible for leading the development and setting

standards of end of life care used. This was achievedthrough using evidence-based guidance, standards,best practice and legislation to develop how services,care and treatment were delivered.

• End of life care was delivered in line with the principlesof the Priorities for Care of the Dying Person (LeadershipAlliance for the Care of Dying Patient, date) For examplethe possibility of dying had been recognised andcommunicated clearly with the patient and those closeto them. Decisions were documented and actions takenin accordance with the patients’ needs and wishes.These were regularly reviewed.

• The needs of families and others identified as importantto the dying person had been actively explored,respected and met as far as possible.

• Individual plans of care, which included food and drink,symptom control and psychological, social and spiritualsupport were in place, co-ordinated and delivered withcompassion.

• The trust had participated in the National Care of theDying audit published March 2016 and had created anaction plan where improvement was identified as beingneeded. Some actions had already been completedsuch as appointing a non-executive to the board torepresent end of life, improved symptom controldocumentation, the development of wards performancemonitoring of for example number of patients receivingassessment of spiritual needs and the development ofthe end of life quality group.

• The trust had an annual audit plan for end of life care.However most local audit activity had not yet benefitedfrom a thorough analysis of the data produced. Despitethat, the specialist palliative care team had acted on theinitial evidence from audit including improvingdischarge planning arrangements (which included ateam member located on a ward to work with staff) andexpanding advance care planning.

• We did not see any discrimination on grounds of age,disability, gender, gender reassignment, pregnancy andmaternity status, race, religion or belief and sexualorientation. The trust supported patients withpotentially life limiting conditions such as dementia andlearning disability and employed two nurses to supportpatients with learning disabilities. We saw evidence thatthey worked with the specialist palliative careteam when necessary.

Pain relief

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End of life care


• Medicines to relieve pain and other symptoms wereavailable at all times. Wards had adequate supplies ofsyringe drivers (devices for delivering medicinescontinuously under the skin) and the medicines to beused with them.

• If a patient was provided with a syringe driver and wassubsequently discharged, the syringe driver wasreplaced by the district nurse team, who returned theoriginal syringe driver to the trust. This ensured that anypatient’s pain and symptoms were managed in acontinuous and consistent way.

• Pain was regularly assessed and reviewed. Staffdemonstrated an understanding of how to assesspatients’ pain when they were not able to articulatetheir needs, by assessing body language or using arecognised assessment tool called the Abbey Pain Scale.

• We saw patient records that showed how patientsshould take pain relief, likely effectiveness and what todo if there were side effects, plans for further follow-up,and how to get help out of hours.

• We reviewed four end of life patient’s medicine records.All patients had appropriate pain relief prescribedincluding anticipatory medicines.

• The trust had participated in the Cancer PatientExperience Survey 2015. They had been ranked in thetop 20% of trusts for two of the 34 questions whichincluded: ‘hospital staff did everything to help controlpain all of the time’.

• Patients and relatives were offered support withemotional and psychological pain by the end of life careteams. This included a specialist psychology service,chaplaincy service, ward staff and the bereavementoffices. Relatives we spoke with confirmed how they hadbeen offered or received support, and we saw this wasdocumented in care records.


• Patient’s nutrition and hydration needs were assessedusing a Malnutrition Universal Screening Tool (MUST)and was followed by appropriate actions such as referralto dieticians for nutritional support which wasdocumented in patients’ individual care plans.

• The records documented discussions with relativesaround what to expect with nutrition and hydration aspart of the dying process.

• We saw mouth care was provided to patients whenrequired to assist with nutritional and hydration needs.

Patient outcomes

• Staff demonstrated an understanding that the end of lifecare was for patients diagnosed with any life limitingcondition and not solely related to patients’ with cancer.This was also reflected in the specialist palliative careteam’s referral audit information.

• The specialist palliative care team provided a trust-wideservice so monitoring systems were set to analyse datacombined from both Gloucestershire Royal andCheltenham General Hospitals.

• The trust took part in the Royal College of PhysiciansNational Care of the Dying Audit in 2014. At this time thehospital achieved compliance with only one of theseven key organisational performance targets. This wasfor having protocols in place for the prescription ofmedicines for the five main end of life patient symptomsfor example breathlessness, anxiety.

• Since the audit in 2014 improvement had been seenwith some patient care outcomes now being achieved.The trust had participated in the End of Life Care Audit:Dying in Hospital in 2015/2016 which was publishedMarch 2016. This scored participating trusts againstseven organisational and 10 clinical key performanceindicators. Based on the most recent National Care ofthe Dying Audit the trust, in comparison with othertrusts had:▪ Performed better than the England average for one

of the five clinical indicators. (Health professionalshad discussed recognition that patient may die inhours or days)

▪ Performed the same as the England average for oneof the clinical indicators (recognition documentedthat patient may die in hours or days)

▪ The trust scored lower for ‘Is there documentedevidence that the needs of the person(s) important tothe patient were asked about?’ scoring 30% versusthe national average of 56%. This meant that somepatients were not being consulted about what wasimportant to them.

▪ The specialist palliative care team had completedtwo audits of the shared care record (June – July2014 and August 2015 – February 2016) andconcluded that symptom observation charts werevery useful, documentation of the reasons fordiagnosing a patient as likely to be dying had

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improved and communication levels were high.However completion rates of the shared care recordhad fallen. Teaching had been implemented andfurther audit was planned.

• We observed a community team meeting where sevenpatients needs were planned using Gold StandardFramework (GSF). The community team who providedspecialist palliative care for patients discharged fromGloucester Royal and Cheltenham General Hospitalused GSF coding to assess and plan priorities for careand treatment for patients. GSF is a systematic evidencebased approach to enable the quality of care and thecoordination between teams to, enable more people tolive and die well reducing inappropriate hospitaladmission.

Competent staff

• The learning needs of staff delivering end of life carewere not all identified. When we requested the trainingneeds analysis for general staff on wards related to endof life care it had not yet been completed. The trust toldus establishing and maintaining records for trainingneeded improvements. The trust planned to improvesystems through the newly established trust end of lifecare strategic group who would aim to complete theaction by September 2017.

• When we requested evidence of current nursingcompetency for syringe driver training we were toldthere were no centrally held records. Records forattainment of competency were held at ward level sothere was no organisational oversight of compliance. Asa result, we were unable to judge the level ofcompetency for this essential equipment.

• We saw some evidence of a yearly programme of end oflife care education for some medical staff. This included:symptom management, levels of care, diagnosing dying,resuscitation and communication skills. For example 44junior foundation doctors attended a care of the dyingsession August 2016, and 33 in September 2016. Othersessions were planned to cover symptom control, ethicsand legal issues and communication. These were newsessions that had not occurred at the time of theprevious inspection.

• Nursing and allied health professionals also had accessto additional training covering resuscitation, syringedriver training, quarterly end of life study days andsymptom management.

• The specialist palliative care team took opportunities toeducate staff in practice by providing micro (short orbrief) teaching sessions. This was done when any of theteam attended ward multidisciplinary team meeting orwere visiting clinical areas. Ward staff we spoke with saidrecent micro teaching sessions had included symptommanagement and setting up syringe drivers. Feedbackwe saw described staff finding the teaching sessionswere helpful

• The specialist palliative care consultants had alsodelivered ‘grand round’ case study presentation trainingin December 2016 and January 2017. This was based onend of life care and the role of the trust wide end of lifequality group. The presentations had been to otherconsultants, junior doctors, chaplains, healthcareassistants, professions allied to medicine and nurses atboth hospitals. The sessions received a high level ofpositive feedback.

• Not all staff in the end of life team had receivedappraisals. 50% of the doctors and 70% of the nurses inthe team had received an appraisal; however dates foroutstanding staff appraisals were booked.

• The bereavement service staff had training to supportbereaved visitors appropriately. This includedcounselling, bereavement care and conflict resolutiontraining.


• Staff, teams and services worked together to delivereffective care and treatment. The in-patient end of lifecare team met every morning to discuss current workand new allocations. Work was allocated based onpatients’ need and urgency. The team worked closelywith the community specialist palliative care team,district nurses and GPs. This supported effective transferof clinical management and follow-up reviews ofpatients upon discharge.

• The specialist end of life team held weeklymultidisciplinary meeting to discuss patients care indetail and review treatment plans. The consultantcompleted ward rounds every week to review patients’care with other hospital staff. The in-patient end of lifecare team worked closely with the community end of lifecare team. This was done to share key informationabout older patients with complex discharge planningneeds.

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• The team worked with staff from other specialties andservices. These attended the team meetings whenavailable and when required. Staff said this ensuredpatients received holistic end of life care and support.

• We saw the shared care record (SCR) in use. This hadbeen designed to record the communication andcollaboration between multi-professionals teammembers, patients and their families. The SCR helped arange of staff identify and care for patients at the end oftheir life

• The chaplaincy service was integrated with the end oflife care in patient and community care teams and otherservices in order to provide and promote good end oflife care. The team worked effectively. The team had anestablished group of volunteers and links with otherfaith groups.

Seven-day services

• There was not a seven day face to face service providedby the in-patient and specialist palliative care team. Thiswas not in line with national guidance. Although thetrust provided a face to face service 9-5 Monday toFriday, out-of-hours there was a telephone advice lineavailable 24 hours, 7 days a week for health careprofessionals.

• The chaplaincy service was available seven days a week,24 hours a day, in order to be responsive to patients’needs. Staff said this ensured most patients’ religious orspiritual needs could be met.

• The hospitals dispensing pharmacy was open fromMonday to Friday during the week, and during themornings on Saturday and Sunday. If wards requiredadditional or alternative palliative medicines out ofhours, clinicians could access a computer database andidentify other areas that had stocks. These medicineswere then obtained elsewhere until the pharmacyreopened. These systems supported end of life patients’fast-track discharge home or into community servicesout of hours, and ensured adequate pain relief wasavailable at all times.


• Staff on the wards had all the information they neededto deliver effective end of life care and treatment topatient’s, we saw paper records that contained▪ risk assessments,▪ care plans,▪ case notes and

▪ Test results.• There had been a recent implementation of a new type

of electronic record. This had caused some difficulties inaccessing records. However the specialist palliative careteam managed to coordinate information betweendifferent electronic and paper based patient recordsystems which supported access for staff to patientrecords. The trust was in the process of implementing asingle electronic system to support better access andexchange of information.

• When patients moved between teams and services,including at referral, all the information needed for theirongoing care was shared appropriately and in a timelyway. This included for discharge, transfer and transitionof care.

• Each patient’s GP received a letter which informed themof clinical details of the end of life care provided. Thiswas sent when the patient had been discharged ortransferred.


• Staff we spoke with in the specialist palliative careteam understood the relevant consent and decisionmaking requirements of the Mental Capacity Act 2005.They also completed documents appropriately.However, we observed some practice by ward basedstaff that resulted in incomplete records so fullinformation relating to patients consent to care andtreatment was not always available in patient records.

• We reviewed 19 do not attempt cardio pulmonaryresuscitation (DNACPR) forms and found that▪ Where patients were identified as lacking mental

capacity or where it was not clear, a mental capacityassessment had not been undertaken and recordedcorrectly in 12 out of 19 records were not completedcorrectly (65%)

▪ Relatives were not involved in discussions in 12 outof 19 (65%). This meant that it was not clear whichpatients lacked the decision making capacity forresuscitation and who needed decisions to be madefor them through the ‘best interests process’ orwhether the correct people had been involved.

• While we found variable quality of completion ofDNACPR records, there was evidence of improvementsfrom the last inspection March 2015. We saw resultsfrom the last two audit of completion in both hospitalssince March 2015. The DNACPR forms showed a steady

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improvement from between 46% and 64% compliancein first audit. The trust had achieved 75% compliance inDecember 2016. The December 2016 audit ofcompletion stated “…significant improvement but weremain a distance away from 100% compliance” with arecommendation to continue education.

• However, relatives we spoke with told us they had beeninvolved by staff in decisions when their relative whowas a patient was no longer able to make decisionsindependently.

• 100% of nurse and non-medical staff within end of lifecare teams had completed Mental Capacity Act (MCA)Awareness training and 90% of medical staff hadcompleted Mental Capacity Act (MCA) and Deprivation ofLiberty training.

• Ward staff we spoke with had an understandingregarding processes to follow if a patient’s ability toprovide informed consent to care and treatment was indoubt. General decisions about care were made byclinical staff and often involved the patients’ relativeswhen the patient was no longer able to give informedconsent. Staff demonstrated that they understood thatmore complex decisions needed to include bestinterests’ discussions and meetings in accordance withthe Mental Capacity Act 2005.

Are end of life care services caring?

Good –––

We rated caring as good because:

• Patients and their relatives were treated with kindnessdignity respect and compassion while they receivedcare and treatment. We saw many written complimentsabout how kind and caring staff were

• Staff took the time to interact with people who receivedend of life care and those people close to them in arespectful and considerate manner.

• Staff and volunteers who worked with the departmentfor spiritual support, bereavement officers and themortuary were aware of and respectful of cultural andreligious differences in end of life care.

• Patients and those people close to them were involvedas partners in the care and this was clearly documentedin patient notes.

• Staff we spoke with understood the impact that apatients’ care, treatment or condition had on theirwellbeing and on those close to them, both emotionallyand socially.

• Emotional support for patients and relatives wasavailable through the in-patient and community end oflife care team, through clinical psychology, socialworker, ward-based nurse specialists and end of lifechampions, the chaplaincy team and bereavementservices.

Compassionate care

• We spoke with a patient receiving end of life care at thehospital and one in the community. We also spoke withrelatives of patients who were receiving end of life care.All described being treated with kindness dignityrespect and compassion while they received care andtreatment.

• Staff took time to interact with people who received endof life care and those close to them in a respectful andconsiderate manner. We observed sensitivecommunication taking place between staff and thedying person, and those identified as important tothem.

• We saw many written compliments about how kind andcaring staff were on the wards and how the trustin-patient and community palliative care team workedso well for patients and their relatives.

• Where possible, patients receiving end of life care wereaccommodated in side rooms to increase dignity andprivacy for them and those visiting.

• Whilst the hospital had very limited accommodation forrelatives, staff supported the needs of relatives as muchas they could when visiting for long periods. Forexample, relatives were offered a pillow and a blanketwhen staying in chairs.

• We were told that bereaved relatives had found itdifficult in the past to navigate from the bereavementoffice to the mortuary. Staff recognised that distressedrelatives found it difficult to follow navigationinstructions between the two services. To improve this,the mortuary staff had designed a white rose symbolused with arrows that marked an easy-to-follow routefrom the bereavement office to the mortuary. Somerelatives had reported they appreciated these signs.However bereavement office staff accompaniedrelatives when they knew people were attending themortuary. Or they arranged for others to accompany

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relatives as the signs were not easy for all to follow.During inspection some building work obscured thesigns at Gloucester and the signs not obscured on bothsites were not always clear of where people should go.

• Staff on wards, staff and volunteers who worked withthe department for spiritual support, bereavementofficers and the mortuary were aware of and actedaccordingly on cultural and religious differences in endof life care. For example: bereavement office staff wereaware of the importance of being able to provide adeath certificate in timely manner. Mortuary staffunderstood the need to be able to release recentlydeceased patients quickly. This supported the spiritualand cultural wishes of the deceased person and theirfamily and carers whilst making sure legal obligationswere met.

Understanding and involvement of patients and thoseclose to them

• We saw that patients who received end of life careservices were involved as partners in their care. Wereviewed care records and saw that staff delivering endof life care had recorded some discussions with patientsand relatives. These included discussions about careand treatments and their implications. We also sawrecords of actions staff should take in response topatients’ and relatives’ wishes. These included requeststo speak with a member of the chaplaincy.

• Ward staff communicated sensitively with patients andthose people close to them so that they understoodtheir care, treatment and condition.

• Patients approaching the end of life were given theopportunity to create a shared care record and anadvance care plan. This included wishes and anyadvanced directives they wished care staff to take ontheir behalf.

• In the Cancer Patient Experience Survey 2015 the trustwas in the top 20% of trusts for two of the 34 questions,in the middle 60% for 28 questions and in the bottom20% for four questions. One of the two questions wherethe trust was in the top 20% was ‘all staff asked patientwhat name they preferred to be called by’

Emotional support

• Staff we spoke with understood the impact that apatients’ care, treatment or condition had on theirwellbeing and on those close to them, both emotionallyand socially. Although some staff told us they found it

difficult to start a conversation with a patient when theward was full and staff were busy. Despite this we sawmany staff engaging with patients and those close tothem.

• Emotional support for patients and relatives wasavailable through the in-patient and community end oflife care team, through a clinical psychology, socialworker, ward-based nurse specialists and end of lifechampions, the chaplaincy team and bereavementservices.

• Patients who received end of life care and those peopleclose to them received the support they needed to copeemotionally with their care, treatment or condition.Patients were enabled to have contact with those closeto them and to link with their social networks orcommunities although there was limited space forrelatives to stay. Chaplaincy volunteers were clear thattheir role was to provide non-religious as well asreligious support. Often offering time for the patient to‘just’ talk with no other purpose than to listen. Staffknew how to contact chaplaincy volunteers and thedepartment for spiritual support at any time.

• Patients were empowered and supported to managetheir own health, care and wellbeing and to maximisetheir independence

Are end of life care services responsive?

Good –––

We rated responsive as good because:

• Services were being planned and delivered in order torespond more effectively to the needs of patient’s. Auditwas used to inform future planning of the service.

• Systems and processes were being reviewed so that thespecialist palliative care team could better understandand respond to service development plans created for2017.

• We saw that patients and relatives had been consultedabout care and their individual wishes had been clearlyrecorded in care plans.

• The in-patient specialist palliative care team wasavailable to ward staff to provide advice and trainingregarding communication and end of life care; thisincluded communicating with patients and carers.

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End of life care


• The trust was one of two sites in the country which hadbeen developing a medical examiner role and improveddeath certification process project since 2008. Benefitsincluded better support for relatives over theexplanation and causes of death as well as ensuringbetter oversight of signing of death certificates

• The specialist palliative care team responded promptlyto referrals, usually within one working day.

• Lessons were learned and improvements were madefrom complaints. This learning was used to improve thequality of care.

However:

• There were no designated beds for people receivingcare at end of life. Side rooms were used when availablebut could not be guaranteed.

• The percentage of patients dying in their preferredlocation and the percentage of patients dischargedwithin 24 hours were not all known for all wards orhospital sites.

• The trust did not have systems in place to identify allpatients in the hospital who had been identified asapproaching end of life.

• End of life complaints were not always handledpromptly and in accordance with trust policy. The trusttook an average of 53 working days to investigate andclose complaints, which was not in line with theircomplaints policy of 35 working days.

Service planning and delivery to meet the needs oflocal patient’s

• Services were being planned and delivered in order torespond more effectively to the needs of patient’s. Planswere underway to:▪ Accurately identify all patients at end of life in the

trust.▪ Audit to inform future planning such as discharge

planning projects based at Cheltenham GeneralHospital, advance care planning and data collectionso that the end of life team could inform betterdecision making with older, frail patients.

▪ Establish a baseline for key performance indicatorswhich would involve information at ward level

▪ Improve coding for the new electronic system so thatthe trust and specialist palliative care team couldunderstand incident reporting and complaintsrelating to their service better.

• Senior staff attended a countywide group attended bycommissioners, other providers and relevantstakeholders. The aim was to share good end of lifepractice and consistency in services through thedevelopment of a county plan for end of life care for2016 - 2019. Other professionals who attended thesemeetings included staff from three local hospices andstaff from other health and social care - services.Outputs from the steering group included thedevelopment of the shared care record for the expectedlast days of life. This was produced and piloted inpartnership with the community palliative care services,the clinical commissioning group and the local hospice.

• Where possible, senior end of life care staff attended theclinical governance meetings at the local hospice. Theyalso took part in a number of working groups whichstemmed from the countywide end of life group.Consultants in specialist palliative care team also mettwice a year with the end of life care teams insurrounding areas to inform care pathways andimproved communication.

• The bereavement office had been involved in a pilotproject with another acute trust since 2008 for theintroduction of medical examiners and reforms to deathcertification in England and Wales. The trust was one oftwo large sites in the country which was developing therole with the department of health and together hadreviewed over 23,000 deaths. Benefits acknowledged inthe review ‘reforming death certification: introducingscrutiny by medical examiners lessons from the pilots ofthe reforms set out in the Coroners and Justice Act 2009’(May 2016) were better support for relatives over theexplanation and causes of death as well as ensuringbetter oversight of signing of death certificates. Thereforms were not yet implemented across the UK andwere planned for April 2018.

• The trust recorded the number of patients at any onetime who had a learning disability or dementia in orderto help plan what services might be needed in future.

Meeting patient’s individual needs

• We saw that patients and relatives had been consultedand their individual wishes had been clearly recorded incare plans.

• The specialist palliative care team was available to wardstaff to provide advice and training regarding end of lifecare. This included communicating and breaking bad

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End of life care


news to patients and carers. This information was alsoavailable on the trust’s website. This ensured staff hadaccess to support when required to provide sensitivepatient information.

• Services took account of the needs of different patient’swith life limiting conditions as well as those patients invulnerable circumstances. For example the trustrecorded 2125 patients who had ‘complex needs’ whohad been in-patients in 2015/16. The trust also recorded540 people with a learning disability had receivedin-patient care in the last year. In order to support staffto meet the needs of this group of patients, the trustemployed two learning disability nurse specialists whoworked with the specialist palliative care team whenappropriate.

• The trust had a policy to support staff to effectivelyprocess patient deaths from different faiths andcultures. Staff we spoke with on wards and in themortuary service were aware of this.

• Translation services were available for end of lifepatients and relatives. Staff who had used these servicessaid they were prompt and efficient in responding toneeds.

• The chapel and two multi faith rooms had a broad rangeof religious texts including Christian bibles, HinduBhagavad Gitas, Muslim Qurans and other literaturerelating to spiritual and non-religious support.

• There were limited family rooms and overnightaccommodation was not available for relatives. This hadbeen discussed at the end of life care quality groupmeeting in January 2017. The action recorded was toremind the trust’s 69 end of life champions on wards toshare knowledge of what was available and helprelatives to know what they could expect of the limitedavailability. Staff were able to direct relatives of patientsreceiving end of life care to areas where they could washif needed during prolonged stays.

• The inpatient specialist palliative care team won anannual staff award the trust patient's choice award 2016,patients and others recognised the NHS staff who hadmade a difference to their lives.

• The consultant in the specialist palliative care team waspart of a multi-disciplinary team who had won thenational Linda McEnhill award 2016. The award wasrecognition by the Palliative Care of People with

Learning Disabilities professional network of excellencein end of life care for individuals with learningdisabilities. Work included improving how differentteams worked better together.

Access and flow

• Whilst referral into the service was dependant on staffidentifying appropriate patients, the end of life teamresponded promptly to referrals, usually within oneworking day. Ward staff demonstrated they understoodhow to make a referral to the specialist team andconsistently reported that the team respondedpromptly. This information was documented in themain medical notes. The service undertook an audit of44 patients referred during a two-week period duringFebruary 2015. Of these, 71% were seen on the sameday of referral and 95.6% were seen within one workingday of referral.

• However the trust was unable to identify the totalnumber of patients in the hospital within a centralrecord receiving end of life care. The trust was planningto adopt a new electronic patient record with the abilityto identify patients who had an advance care planningdocument or to be able to search for patients beingcared for at end of life or identify specific needs aroundend of life care had been built in. The system was notyet in use as it had been delayed.

• Access to the spiritual support provided by thechaplaincy service was audited. This was done in orderto identify areas of high demand and low use and tounderstand if staff needed to be made more aware offthe support available, including future planning of thespiritual support department.

• Gloucester Royal Hospital chaplaincy call-outs (2016)

• Seven wards had not called on call chaplaincy• 19 wards had called on call chaplaincy• Ward and other staff had called on call chaplaincy on a

total of 100 occasions• 144 out of hours call-outs across trust

• A review of preferred place of care for patients wasundertaken between July and August 2016. In 21 cases65.6% successfully achieved a preferred place of care ordeath (PPD) where information was recorded. Thisreview highlighted potential difficulties with theplanned electronic patient record and recording of thedata. As a result, the importance of clearly documentingPPD was raised and where discussion was not

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End of life care


appropriate or not wanted by the patient, to ensure thiswas known by the team. The specialist palliative careteam also planned to liaise with team developing thenew electronic patients record so that information wasable to be identified trust wide

• The trust planned for discharges for patients at end oflife to be completed within two hours of booking.Discharges could be booked the day prior to dischargeto ensure a planned approach. Ambulance servicesrecognised the Do Not Attempt Cardio Pulmonaryresuscitation (DNACPR) documentation and this wasprovided to them at the point of patient transfer. Wardstaff and the rapid discharge team said that most end oflife discharges were achieved within 24 to 48 hours,although there were sometimes delays for patients wholived in rural areas.

• Discharge for patients at end of life took place at anappropriate time of day. All relevant teams and serviceswere informed and discharge took place only when anyongoing care was in place. Most delays experienced forend of life care were attributed to the lack of availabilityof care in the community.

• Between October 2015 and September 2016, the mainreasons recorded for delayed transfer of care for allpatients from the trust were ‘waiting further NHSnon-acute care’ (35.1%), followed by ‘completion ofassessment’ (29.8%). The trust’s percentage share for‘waiting further NHS non-acute care’ was almost doublethe percentage share for the England average. Therewere no specific figures available for end of lifedischarge delays.

• There were 1693 referrals to the specialist palliative careteam between April 2014 March 2015. Cancer relatedreferral accounted for 1175 (69%) and non-cancer 518(31%). There were 2067 referrals between April 2015 andMarch 2016 pf which Cancer referrals numbered 1587(77%) and non-cancer 480 (23%).

• A policy was in place for the rapid release of a deceasedpatient from the mortuary which supported the respectof cultural wishes of deceased patients. Medical andmortuary staff demonstrated an understanding of theprocesses to follow, and we saw documentationconfirming this.


• Lessons were learned and improvements were madewhen care provided was not as good as expected.Significant learning was focussed on improvingbereaved relatives experiences in the mortuary and careof those who had recently died.

• Patients who used the service and those close to themknew how to make a complaint or raise a concern andwere encouraged to do so. Between November 2015and October 2016 there were a total of 18 complaintsabout end of life care.

• A formal complaint record was maintained. This showedcomplaints were handled confidentially, with a regularupdate provided for the complainant.

• However complaints were not always handledeffectively. The trust took an average of 53 working daysto investigate and close complaints, which was not inline with their complaints policy, which statedcomplaints should be responded to in 35 working days.

• Patient care was the most complained about themewith 13 complaints, followed by admission anddischarges with two complaints.▪ There were 15 complaints for Gloucestershire Royal

Hospital: of which ‘patient care’ received the highestnumber of complaints; 11 (73%)

• Processes were in place for the learning fromcomplaints to be visible at board level.

Are end of life care services well-led?

Good –––

We rated well-led as good because:

• The leadership and culture of end of life the specialistpalliative care team in the trust reflected the vision andvalues of the trust.

• The trust had a clear vision and strategy to deliver careat end of life linked to national best practice includingPriorities for Care of the Dying Person set out by theLeadership Alliance for the Care of Dying Patient’s.

• The governance framework for end of life care ensuredthat responsibilities were clear and that quality,performance and risks were understood and managed.

• Priorities were identified at the specialist palliative careteam meetings for consideration at the trust’s qualitycommittee meetings.

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End of life care


• Systems were in place to learn from incidents thatoccurred in end of life care.

• Leadership, encouraged openness and transparencyand promoted good quality care. There were leads onthe wards for delivery of end of life care whichsupported the development of high quality end of lifecare.

• Staff felt respected and valued. There was a strongemphasis on promoting the safety and wellbeing of staffdelivering end of life care in the community.

• Services had been continuously improved andsustainability supported since the last inspection.

• We saw examples where leaders and staff took part incontributing to their own and others continuouslearning, improvement and innovation

However:

• There was no risk register specific to end of life care forthe trust so there was no easy trust wide oversight of riskrelating to the service.

• There was a program of internal and national audits forend of life care, which were on time. However most localaudit activity had not yet benefited from a thoroughanalysis of the data produced.


• The trust had a clear vision and strategy to deliver careat the end of life. The vision was developed by the endof life quality group and was presented to the qualityand performance committee in December 2016. Thevision was to embed pride in end of life care deliveryacross the trust to ensure that end of life care was goodas it can be for every individual and those important tothem, every time. Following the previous inspection,work had been completed by members of end of lifecare team on the vision and strategy. We saw a realisticaction plan to achieve the 10 actions considered mostimportant by the team for the Board. Compliance wasmonitored by the executive and non-executive leads forend of life care through an action plan with setdeadlines.

• The end of life vision also included improving patientexperience, clinical effectiveness, the establishment ofthe end of life care group and patient safety. Thestrategy and vision was presented to the quality andperformance committee. Following the presentation thecommittee agreed that end of life care should form partof the essential training for the trust. We saw three

different levels of training proposed during inspectionwith end of life champions being in the first wave andstaff of the trust all completing an end of life module.The recommendation was referred to the education andlearning development unit. The trust charter for end oflife care (an explicit statement of what various parts ofthe trust would do to support end of life care) wasunderway. The charter, once finalised, was to bepresented to the Board.

• The specialist palliative care team understood what thevision and values were. Some general staff on wardswere aware of it, most usually end of life champions andward sisters. The specialist palliative care team and thetrust were at an early stage of development and thewritten strategy for the hospital with defined work planpriorities for the present and future recently completed.

• The strategy reflected the learning and developmentwithin the specialist palliative care team and findings ofprevious inspection reports. It reflected the currentchallenges the trust faced in relation to end of life careservices. Which were▪ Continuing and improving education▪ Understanding of performance and safety

• The trust had included a quality priority in the 2016/17quality account which was to improve end of life care.


• The governance framework for end of life care ensuredthat responsibilities were clear and that quality,performance and risks were understood and managed.The strategic end of life group reported directly into thetrust quality and performance committee, chaired bythe Chief Executive. The membership of the quality andperformance committee included. The medical director,the specialist palliative care team consultant and arange of other staff including the non-executive director,senior ward nurses, chaplain and patient experiencemanager.

• Processes were followed to provide assurance to theboard regarding safety issues. The end of life carequality group and medical director provided regularreports to the board.

• Although there was no specific risk register for end of lifecare, risk management processes were followed.However oversight of all end of life risk was not easy.

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End of life care


Priorities were identified at the specialist palliative careteam meetings for governance and fed into divisionalmeetings and on through to the trust’s qualitycommittee.

• Systems were in place to learn from incidents thatoccurred in end of life care for example mortuaryincidents and discharge planning for patients at end oflife.

• There was a program of internal and national audits forend of life care, which were on time. However most localaudit activity had not yet benefited from a thoroughanalysis of the data produced. This was due to somedeadlines and projects only being implementedrecently due to recent reduction in staff shortages withinthe specialist palliative care team. Staff shortages hadnot affected other aspects of end of life care practice.

• However the trust had a programme and strategy tounderstand and improve on hospital based mortalityindicators related to end of life patients. In January 2017the known challenges were listed as;▪ The coding of palliative care input was low by

national comparison. As a cancer centre a higherlevel of patients falling into a palliative category hadbeen expected. This was currently under reviewbetween the specialist palliative care team and thecoding team. Better coding was hoped to lead tobetter information about numbers of patients andany delays they experienced.

▪ The trust was aware of the delayed discharge ofpatients. Some patients then became too unwell fortransfer due to the delay. The improved discharge ofthose patients choosing to receive their end of lifecare at home would give a key indication of a systemdriven by high quality care.

▪ Work was currently underway to review admissionpathways as part of the emergency pathway review.This was planned to allow more specialist input intopatient care prior to admission. This would improveaccuracy of initial diagnosis and ensure moreappropriate admissions and avoid inappropriate endof life admissions.


• The leadership and culture of specialist palliative careteam in the trust reflected the vision and values of thetrust. Leadership, encouraged openness andtransparency in decision making.

• The medical director was the executive lead for end oflife care responsibilities. The non-executive leadcontributed by challenging timescales and decisionsregarding end of life care planning and delivery. Staffdescribed them as understanding the issues within thehospital and being active, visible and supportive.

• The specialist palliative care team were led by thespecialist consultant with support through five inpatient advanced nurse practitioners. Two of the fiveadvanced nurse practitioners were based atGloucestershire Royal two were based at CheltenhamGeneral Hospital with one working across both sites.Leadership was also through three community teamadvanced nurse practitioners based at GloucestershireRoyal Hospital and with additional work bases at threehospices in the area.

• There were 69 end of life champions in the trust basedon wards The ‘champions’ provided additional localward leadership with senior ward nurses for the deliveryand development of high quality end of life care.


• There was an open culture within the service where staffwere able to raise concerns. Staff felt respected andvalued and there was a strong emphasis on promotingthe safety and wellbeing of staff delivering end of lifecare.

• The culture was centred on the needs and experience ofpeople who received end of life care. Ward staff felt endof life care was an important part of their work. Howeverwhen busy felt it was something that was difficult toensure was a priority.

• Staff and teams worked collaboratively, to deliver goodquality care.

Public engagement

• Patients and those close to them who used the end oflife care were engaged and involved. Patients and thoseclose to them shared their experiences with both thein-patient and community specialist palliative careteam. Some experiences were used anonymously toinform staff training and to improve process such asenabling better discharge planning.

• While there was no specific Friends and Family Test forthose in receipt of end of life care, the overall hospitalresponse was generally worse than the England averagebetween November 2015 and October 2016. In the latest

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End of life care


period, November 2016 trust performance was 95.2%which is the same as the England average of 95.2%. Thetrust’s performance had stayed consistently between93% and 97%.

• In the Cancer Patient Experience Survey 2015 the trustwas in the top 20% of trusts for two of the 34 questions,in the middle 60% for 28 questions and in the bottom20% for four questions.

Staff engagement

• Staff we spoke with in specialist palliative care team feltactively engaged and that their views were reflected inthe planning and delivery of services and in shaping theculture.

• Leaders and staff understood the value of raisingconcerns and appropriate action was taken as a resultof concerns raised. For example we saw that concernsover team resources had been responded to withincreased recruitment.

• There was a trust wide end of life care steering group orcommittee, which was representative of the breadth ofstaff involved in end of life care which ensured decisionswhere informed by a range of staff involved.

• We saw records which showed that the majority of staffwho attended training courses facilitated by the end oflife care team gave positive feedback. Staff said this wasused to plan and improve future training sessions.


• Improvements had been made to the service since thelast inspection. Staff had considered developments toservices and, the impact on quality and sustainabilitywas assessed and monitored which had led to anincrease in nurse and doctor provision.

• End of life care performance measurements were beingdeveloped and implemented

• There was a trust wide end of life care quality group,established during September 2016. The group had amembership of medical nursing, allied healthprofessionals, non-executive, chaplaincy and hospitalsite management. This group were aiming to implementthe countywide and local end of life care strategy.

• Think '333' was a prompt for improved dischargeplanning which required prescriptions, communicationand documentation needed from wards to facilitatesmooth discharge for patients receiving end of life care.The tool was beginning to be widely used by thehospital wards, having been developed by nurses in thespecialist palliative care team and medical stafffollowing responses to incidents recorded.

• There were a team of end of life champions, basedacross the inpatient wards. They supported the deliveryof end of life care on wards. They attended regular trustmeetings and were developing an end of life care workprogramme.

• Since 2008 Gloucester Royal Hospital and thebereavement office had been involved in a pilot projectwith another acute trust for the introduction of medicalexaminers and reforms to death certification in Englandand Wales. Benefits acknowledged in the review‘reforming death certification: Introducing scrutiny byMedical Examiners Lessons from the pilots of thereforms set out in the Coroners and Justice Act 2009’(May 2016) were better support for relatives over theexplanation and causes of death as well as ensuringbetter oversight of signing of death certificates.

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End of life care




Overall

Information about the serviceThis report focuses on our inspection of the outpatient anddiagnostic imaging departments located at GloucestershireRoyal Hospital.

Gloucestershire Hospitals NHS Foundation Trust providesoutpatient and diagnostic imaging services to a populationof over 600,000 people. These services are provided inoutpatient and diagnostic imaging departments at theCheltenham General Hospital and the GloucestershireRoyal Hospital. The same team of senior staff, who workbetween both sites, manage the general outpatient anddiagnostic imaging departments at both hospitals. Someoutpatient departments are managed by the specialtiesthemselves, for example the trauma and orthopaedicdepartment.

Across all Gloucestershire Hospitals NHS Foundation Trustsites, between April 2015 and March 2016, there were815,638 new and follow-up outpatient appointments ofwhich 407,362 were held at Gloucestershire Royal Hospital.During the inspection, we visited a range of outpatientclinics on the Gloucestershire Royal Hospital site includingphysiotherapy, oncology, dermatology, ophthalmology,respiratory medicine, general medicine, general surgery,ear nose and throat, urology, audiology, rheumatology,trauma and orthopaedics, gynaecology, pain clinic andclinical psychology.

We also visited the radiology department, including plainfilm imaging, magnetic resonance imaging, computedtomography, ultrasound, nuclear medicine, screening andmedical physics.

Between January 2016 and October 2016 the diagnosticimaging department at Gloucester Royal hospital reportedon 102,888 examinations.

On our last inspection in March 2015, the diagnosticimaging and outpatient departments were rated asrequires improvement for both safe and responsive

domains. There were three areas requiring improvementwhich included storage of records, referral to treatmenttimes and availability of emergency resuscitationequipment.

During this inspection a team of inspectors and specialistadvisors spoke with 37 members of staff, includingmanagers, sisters, nurses, healthcare assistants,consultants, radiographers, physiotherapists, receptionists,secretaries and bookings staff.

We reviewed six sets of patient records, and spoke with 17patients and their relatives to seek their views of theservices provided.

As part of this inspection, CQC piloted an enhancedmethodology relating to the assessment of mental healthcare delivered in acute hospitals; the evidence gatheredusing the additional questions, tested as part of this pilot,has not contributed to our aggregation of judgements forany rating within this inspection process. Whilst theevidence is not contributing to the ratings, we havereported on our findings in the report.




Summary of findings• The service did not have sufficient arrangements to

keep clinical and patient areas clean. There was nocleaning carried out over the weekend in diagnosticimaging, and some outpatient treatment rooms andwaiting areas were visibly dirty.

• There was not a reliable system to track the numberof temporary notes being used since theimplementation of a new computer system care, andstaff were finding it difficult to trace patient notes.

• There were not sufficient arrangements to ensurestaff had access to or knew where to accessemergency equipment. Some staff were unsure oftheir responsibilities in a resuscitation situation, andstaff in ophthalmology did not know where to locatetheir nearest defibrillator.

• Patients were not protected from avoidable harm inthe therapies department as cleaning chemicalswere not stored securely.

• The hospital was not meeting the 62 day waiting listtarget for cancer patients.

• Patients were experiencing delays in diagnosis andtreatment because the diagnostic imagingdepartment had a reporting backlog of 19,500 films,and was not meeting its five day reporting target foraccident and emergency x-rays.

• A significant typing backlog was causing delays insending out patient letters impacting on patientsafety, diagnosis and on-going treatment.

• Implementation of new IT systems had impacted onwaiting lists as some specialties could not see theirlive waiting lists.

• The trust was not meeting referral to treatment targetin all specialities, and patients were waiting longerfor to access care and treatment.

However;

• Incident reporting had improved and in one case thetrauma and orthopaedic department to take steps toreduce pressure ulcers. Staff confirmed they nowreceived feedback from incidents they reported.

• The diagnostic imaging department conductedinvestigations and had raised safety alerts with anequipment manufacturer which had resulted inchanges to practice.

• Cleaning and infection control procedures hadimproved in ophthalmology since the last inspection,and there were good decontamination processes inother outpatient departments for equipment thatwas re-useable.

• Diagnostic imaging were negotiating one cost serviceand maintenance contracts for scanners andequipment.

• Patient were able to access services when theyneeded to and rapid access assessment clinics wereprovided in some specialities, and some clinics wereperforming airway assessments via Skype.

• The hospital had introduced a new waiting listvalidation process to discharge patients’ on-goingfollow up care to community based services such asGPs.

• A project placing therapists on wards had helpedincrease patient discharges, and radiographersattended ward briefings to identify inpatients waitingfor scans.




Are outpatient and diagnostic imagingservices safe?



• There was no cleaning carried out over the weekend indiagnostic imaging, and some outpatient treatmentrooms and waiting areas were visibly dirty.

• Staff were finding it difficult to trace patient notes sincethe introduction of a new computer system, and therewas not a reliable system to track the numbers oftemporary notes being used since its implementation.

• Some staff were unsure of their responsibilities in aresuscitation situation, and staff in ophthalmology didnot know where to locate their nearest defibrillator.

• Cleaning chemicals were not stored securely in thetherapies department.

However;

• The trauma and orthopaedic department was takingsteps to reduce pressure ulcers, and had improved thereporting of these incidents. Staff confirmed they nowreceived feedback from incidents they reported.

• The diagnostic imaging department conductedinvestigations and raised safety alerts, and had changedpractices as a result.

• Cleaning and infection control procedures hadimproved in ophthalmology since the last inspection,and there were good decontamination process in theoutpatient departments for equipment.

• Diagnostic imaging were negotiating one cost serviceand maintenance contracts for scanners andequipment.

Incidents

• Staff consistently reported incidents and understoodtheir responsibilities to raise concerns using theelectronic reporting system. Staff understood why it wasimportant to record safety incidents, concerns and nearmisses, both internally and externally. An example ofthis was in the trauma and orthopaedics department,where staff had noticed a number of grade one and twopressure ulcers developing in patients with plaster casts.

• Since our last inspection, incident reporting hadincreased when compared to other similar services and

England averages. Between November 2015 andOctober 2016 the diagnostic imaging and outpatientdepartment reported 605 incidents. 512 were graded asno harm, 77 minor harm, 9 as moderate harm, 4 asmajor harm, 0 as death. Staff told us they understoodhow incident reporting helped the trust identify andmonitor patient safety.

• A trust wide focus work group for leads from the fractureclinic was focussing on the prevention of pressure ulcersfrom grade 2 to grade 4. Work was aimed at not onlyinpatients with fitted plaster casts and appliances, butfor patients in the community and nursing homes. Wesaw information leaflets on preventing pressure ulcersand ‘care of your cast’, which patients were dischargedwith. The team had developed over the last six months aplaster, splint and brace observation chart. The wardstaff used the observation chart which included checksfor signs of rubbing, capillary refill, soiled casts andodour and ensuring the patient had been given a care ofcast leaflet.

• When things went wrong in the outpatient anddiagnostic imaging departments, thorough and robustreviews or investigations, including all staff involved,were carried out. In one example we heard how indiagnostic imaging a patient suffered blistering to thehand after an iodinated contrast injection had leakedinto the tissue around the injection site. Theinvestigation identified a problem with the type ofintravenous cannula used for these types of pressurisedinjections. As a result, the cannulas were removed fromuse and replaced with a different type of cannula.

• When things went wrong in outpatients and diagnosticimaging, lessons were learned and action was taken aresult of investigations. Staff we spoke with told us theyreceived feedback from incidents they reportedalthough this was sometimes verbal. As a result of theexample incident above, we saw the identified cannulaswere withdrawn from use, and the policy tore-cannulate inpatients when they required apressurised contrast injection was revised. All staff wespoke to in diagnostic imaging were aware of the newcannulation policy, and confirmed all failed contrastinjections were reported via the trust electronic incidentreporting system. However, senior staff identified thepossibility that there may be patients with delayedreactions who they did not know about, as they hadgone to their GPs for treatment after their investigation.




• People who used services were told when they wereaffected by an incident and given an apology and theywere informed of any actions taken as a result. We sawthat the patient with blistering to the hand, had receivedan apology and been sent for further medical treatmentfor the blistering. We also saw that they had been toldabout the actions the diagnostic imaging departmenthad taken around the type of cannula used, whichincluded raising a safety alert via the health and safetycommittee and to the manufacturer.

Duty of candour

• Regulation 20 of the Health and Social Care Act 2008(Regulated Activities) Regulations 2014 is a regulation,which requires the organisation to be open andtransparent with patients when things go wrong inrelation to their care and the patient suffers harm orcould suffer harm, which falls into defined thresholds.Staff we spoke with were aware of this legislation anddemonstrated good understanding of theirresponsibilities under it.


• Reliable systems were in place to prevent and protectpeople from healthcare-associated infections. Forexample the outpatient and diagnostic imagingdepartments collected twice monthly data about handhygiene, and the most recent data available showed99% compliance in July and 100% compliance in Augustand September 2016 across both hospital sites.

• Standards of cleanliness and hygiene were maintainedin all clinical areas we visited, and staff could explainhow this was consistently achieved. For example in thetrauma and orthopaedic outpatients department, anurse was responsible for cleaning and topping thestores up in each clinic room. Trained nurses had a dailychecklist to complete which covered suctionequipment, oxygen, and blood glucose equipment. Ofthe two weeks of lists checked all were signed anddated.

• Most areas we visited were visibly clean and clutter free.However; in the orthodontics department we saw stafftea making facilities in the clinical area, and inophthalmology we saw visibly dirty surfaces in severaltreatment rooms and the patient waiting area. Staff told

us the waiting areas were cleaned by the domesticteam, but clinical areas were cleaned by the clinic staff,however we did not see any cleaning schedules orchecklists to support this.

• On our previous inspection we saw there was no visiblesystem to enable staff to identify if a piece of equipmentwas clean prior to use. On this inspection staff told usthere was still no such system in place, and if equipmentwas in a store cupboard, it was assumed to be clean asit was part of the cleaning of that store cupboard.Cleaning took place in the mornings before clinicsstarted, and was carried out by the clinic staff. We sawcleaning checklists were complete and up to date, andmentioned pieces of equipment in the cleaning tasksoutlined on the checklist.

• Staff in the Ear, Nose and Throat (ENT) department hadgood procedures for the cleaning of reusableequipment, and showed us the decontaminationprotocol for the nasoendoscopes used in the clinics.This involved a three step disinfection process, whichwas in line with Department of Health best practiceguidance HTM 01/06 and hospital policy. In theOrthodontics department, staff explained how all dentalequipment used in clinics was sent to the central sterileservices department (CSSD) for decontamination in linewith Department of Health best practice guidance HTM01/05 and hospital policy.

• The trust had set a target for 100% of staff to undertakeinfection prevention and control training. The mostrecent data available showed this had not been met inJuly 2016 (94% compliance) and August 2016 (93%compliance).

• Staff we spoke with could explain the importance ofhand washing, and understood when to use soap andwater or antibacterial hand gel. We saw staff were eitherwashing their hands before and after patient contact orusing antibacterial hand gel which was in line withNational Institute for Health and Care Excellence (NICE)guidance quality statement 61. We also saw all clinicalstaff were bare below the elbow, in line with trust policy.

• We saw antibacterial gel dispensers in all consultingrooms and patient waiting areas. Staff were able toaccess hand wash basins throughout the clinics anddepartments and posters displaying best practice forhand hygiene technique were displayed.

• Staff took appropriate precautions when seeing patientswith suspected communicable diseases or infections.For example, patients with suspected or confirmed




communicable diseases were placed at the end ofappointment lists to allow thorough cleaning to takeplace after the scan or investigation, and to helpminimise contact between patients.

• Personal protective equipment, such as aprons andgloves were readily available in all areas and staff coulddescribe how and when to use this equipment. Staffcould explain how this equipment protected bothpatients and staff from the possible spread of healthcareassociated infections, but also explained how it was nota replacement for good hand hygiene.

• Staff in ophthalmology told us of changes they hadmade to their cleaning procedures as a result of learningfrom a review of infections in patients receivingintravitreal eye injections at the Cheltenham GeneralHospital clinic. Changes were made to cleaningprocedures across all ophthalmology clinics. Staff wereawaiting audit data to assess if the infection rate hadreduced as a result.

• In diagnostic imaging there was one dedicated cleanerwho was responsible for the whole of the department.Sometimes the cleaner was re-located to inpatientwards when domestic staffing was low which staff saidhad an impact. The cleaner worked 07.00-15.30 threedays a week and 07.00 -13.30 on two days. Staff told usthere was no cleaning carried out in the diagnosticimaging department outside of these hours, unlessrequested


• Facilities and premises in the main outpatientdepartment were designed in a way that kept peoplesafe. The general outpatient department was a relativelynew part of the hospital with large amounts of glassused in the walls making it light and airy. However, wewere told the area could be very cold in winter and verywarm in summer, and despite escalating this to thecompany who owned the building, they had not found away to regulate the temperature effectively. This issuewas recorded on the department’s risk register as it hadbeen on our previous inspection, as patients hadreported feeling faint in warmer months.

• Equipment was regularly and adequately maintained bythe medical electronics department and through anumber of external maintenance contracts in diagnostic

imaging. Staff used equipment safely and we wereshown standard operating procedures for equipment.All electrical safety test stickers we saw on equipmentwere within their service dates.

• Senior staff in diagnostic imaging told us they werelooking into new ways of negotiating maintenancecontracts, which would involve a one off cost andinclude all parts and labour associated with servicingdiagnostic imaging equipment. Staff hoped this wouldbe useful in future budget management as all costswould be known. Senior staff told us they had recentlyhad to replace three x-ray tubes (through normal wearand tear) which had not been included in servicecontracts and had required additional funding.

• Senior staff in diagnostic imaging told us a magneticresonance imaging (MRI) scanner had been authorisedfor purchase, but had been put on hold for over a yeardue to financial and budget pressures. The purchasewas now going ahead again. There had been no impacton patients from the delay and staff had been able tomanage their waiting lists with minimal impact.

• There were systems for managing waste and clinicalspecimens including sharps bins, and in all clinical areaswe visited we saw sharps bins were temporarily(partially) closed in-between use as recommended bythe Department of Health management of healthcarewaste HTM 07-01 (2013).

• Resuscitation equipment was not readily available ineach outpatient area we visited but equipment we didlook at was stored and checked in line withResuscitation Council best practice guidance. Thetherapy department did not have its own resuscitationtrolley, but staff could explain the procedure forsummoning help and knew where the nearestresuscitation trolley and defibrillator could be found.However, in ophthalmology we saw the resuscitationtrolley did not have a defibrillator, and staff we spoke todid not know where the nearest defibrillator was kept.On our previous inspection we found the trauma andorthopaedic department did not have its ownresuscitation trolley. Since then a risk assessment hadtaken place which showed risks had been consideredwith the outcome that staff would summon help fromthe accident and emergency department located nextto the trauma and orthopaedic department.

• In the ophthalmology department, we did not see anyresuscitation equipment for children, and staff told us




this had been risk assessed by the resuscitationdepartment and the risks were mitigated by the crashteam bringing dedicated paediatric equipment withthem when they attended the crash call.

• The trust risk assessment used to decide which areas inthe outpatient clinics did not need resuscitationequipment used information from previous 2222incidents and discussions with clinical managers todecide where trollies were placed. If an area had nothad a cardiac arrest in the last five years, a trolley wasnot placed there. Staff also told us that if the use of anarea changed, then an immediate reassessment by theresuscitation team was done.

• The imaging service ensured that non-ionising radiationpremises, in particular MRI scanners, had arrangementsin place to control the area and restrict access. All MRIscanners had coded locked doors, to prevent peopleaccessing the scanner accidentally and being exposedto the magnetic field.

• Toilet facilities for the trauma and orthopaedicdepartment and diagnostic imaging waiting areas werelimited as there were two cubicles for both departmentswhich were used by both patients and staff. Pictorialsignage identified which cubicles were for men andwomen and which included facilities for disabled usersand baby changing.

• Access to disabled toilets throughout the outpatientdepartment was appropriate although, there were nopull alarm cords in several of these meaning anyoneusing them may not be able to summon help in anemergency or if they required assistance . Alarm buttonswere situated on the wall by the door, but would beinaccessible if a patient fell and could not reach thebutton.

• Staff in the trauma and orthopaedic outpatientsdepartment had tea and coffee making facilities in theclean utility room. Staff then walked through thedepartment with hot drinks to consume them in theclinic rooms, and told us there was not easy access to abreak area or staff room.

Medicines

• There were reliable systems for recording and storing ofmedicines, medical gases and contrast media. Theoutpatient and diagnostic imaging departmentsmonitored minimum and maximum temperatures ofthe refrigerators and rooms where medicines werestored and we saw records of this which were complete

and up to date. Staff could explain what to do iftemperatures had exceeded certain thresholds and hadan understanding about the effects temperaturefluctuations could have on the medicines they heldstock of.

• All of the refrigerators we looked at in outpatients anddiagnostic imaging had daily check sheets recordingminimum and maximum temperatures, which were allsigned and up to date, with no entries missing.

• The trust provided staff with medications managementtraining, and staff showed us policies relating tomedications management were available to them online. However, the trust had set a target for 90% of staffto have completed medication management training,and in the outpatient department this target had notbeen met, with 84% of staff receiving this training.

• There were systems in place to maintain up to daterecords and alerts on the Control of SubstancesHazardous to Health (COSHH) in some areas we visited.We saw evidence in the trauma and orthopaedicoutpatients departments of folders with up to dateinformation. However, in the therapies department wesaw an unlocked room with chemicals which weresubject to COSHH left out on a cleaner's trolley.

• There were systems in place to ensure the safety ofcontrolled drugs administered in outpatients. Allcontrolled drugs were stored securely in lockedcupboards. We carried out random checks of a numberof controlled drug record books which showed allentries were complete and up to date, with noomissions.

• Prescription pads (knows as FP10 forms) were storedsecurely and were signed in and out of each clinic at thestart and end of each clinic session. We saw FP10’sstored in plastic wallets, with a record sheet containingeach FP10 reference number, the patient’s hospitalnumber and the signing doctor’s name and date. Stafftold us they cross checked the sheet with the remainingprescriptions to check all of the prescriptions wereaccounted for. Staff could describe what to do if aprescription had gone missing, but could not recall anoccasions when this had happened. We saw all FP10swere locked in secure cupboards in unattended clinicrooms.




• The nuclear medicine service did not take account ofThe Medicines (Administration of RadioactiveSubstances) Regulations 1978 (MARS), as we did not seean up to date list of practitioners who could approvenuclear medicine procedures.

• Diagnostic imaging had worked with the pharmacydepartment to provide competency based training forhealthcare assistants working in diagnostic imagingwhich allowed them to administer sodium chloride as aflush for patients having contrast injections, under atrust wide patient specific directive (PSD).

• An outpatient survey carried out in August 2016 hadbeen completed across all trust sites and 32% ofpatients who took part in the satisfaction surveyreported that they were not fully involved in decisionsover best medication, 12 % of patients said they had notbeen told how to take their new medications, 13% hadnot been told how to take their current medications,17% had not had the reason for a change tomedications explained and 40% were not told of sideeffects. These results showed the trust was doing betterwith regard to medications satisfaction when comparedto some other trusts. The trust had an action plan whichfocussed on 13 areas for improvement identified withinthe survey, including improvements around bettercommunications with patients before and duringappointments, and continuity of care.

Records

• Patient care records were accurate, legible, competeand up to date, and we found this to be true of the sixsets of records we looked at. There were systems inplace for managing records which were communicatedto staff, which included a delivery and collection service.Notes were delivered to a lockable room in the traumaand orthopaedic outpatients department and a staffmember was assigned to go through these notes inpreparation for the following day’s clinics. However, intwo outpatient clinics we saw an unlocked, unattendedroom used to store patient records which wereaccessible from patient waiting areas.

• There was a reliable system for ensuring medicalrecords availability for clinics which was auditedregularly. The trust reported that across all sites 1.5% ofpatients were seen without their full medical recordbeing available between January 2016 and November2016. Any records that were not available weresubstituted with a set of temporary records. These

temporary records contained a copy of the referral,discharge summary or letter from a previousappointment depending on the patient pathway.Clinicians also had access to pathology results,diagnostic imaging results and clinic letterselectronically within the outpatient department viaother hospital internal IT systems.

• Staff in the outpatient departments told us missingnotes were reported as incidents. Since the introductionof new IT system in December, staff said the instances oftemporary and missing notes had increased; however,no data had been collected to show this. The new ITsystem was currently used to track patient notes andschedule appointments. Future roll outs of the projectwere planned to include electronic copies of patientcare records. This was currently limited to outpatientreferral letters, inpatient discharge summaries,emergency department attendance records and someobstetric records.

• Medical records staff told us that since the introductionof a new computer system, staff were not booking notesin and out correctly, which made tracking the notesdifficult leading to an increase in the numbers oftemporary files being made up. We requested datacollected after the introduction of the new IT system fornumbers of temporary notes but none was provided.

• Measures had not been taken to increase compliancewith notes availability; however some records, includingGP and clinic letters were available electronically whenpaper records were unavailable. Staff told us the nextrole out of the new system would address some of thenotes issues, however, they felt the notes traceabilityissue was due to poor staff training on the system.

• We were told of a situation in an outpatient’s clinicwhere staff had problems setting up a clinic on the newsystem. This resulted in the clinic being double bookedand increasing from 31 to 62 patients. An extraConsultant was obtained and the patients were all seenhowever the notes could not be ordered in time, andpatients were seen without compete medical records.

• There were systems in place to record which patientsrequired additional support in order to aid their careand treatment. We were told that at this stage ofimplementation the new system did not alert staff topatients who had mental health conditions, learningdisabilities or dementia. If patients were known to beliving with a diagnosis of dementia then a purplebutterfly was attached to their records.




• Staff told us that a yellow sticker was placed on the frontof notes to let clinic staff know if a patient was livingwith a mental health diagnosis. Staff in the trauma andorthopaedic outpatients department told us that themental health liaison team would pre alert staff whenthey knew a patient living with a mental health issuewould be attending clinic.

Safeguarding

• There were systems, processes and practices in place tokeep people safe, and these systems and processeswere communicated to staff. The trust had set a targetfor 90% of clinical staff to have completed safeguardinglevel two training for both adult and children. The trusthad met this target for medical staff; however 83.9% ofnursing staff had completed safeguarding level twotraining for children.

• There were arrangements in place to safeguard adultsand children from abuse that reflected the relevantlegislation and local requirements, and staff understoodtheir responsibilities. We saw information displayed inmost outpatient areas we visited, which was clear andcontained contact information for patients and staff. Inthe outpatient departments we visited, we saw staffcarrying laminated cards with flow charts detailing whatto do in case a safeguarding concern for a child or adultneeded to be raised. There was a clear process of how toescalate concerns and who to contact, which staff wereaware of.

• Staff told us in one outpatient clinic at another site, ayoung person had been treated as having adult capacitywhen they attended alone for an appointment. We sawevidence of learning from this incident shared acrossthe whole trust and staff we spoke to were aware of this.

• In the diagnostic imaging department, two members ofstaff acted as safeguarding champions, and had beentrained to level three in both adult and childsafeguarding. We were shown a spread sheet which thestaff used to monitor the diagnostic imagingdepartments compliance with safeguarding trainingagainst the 90% trust target, which the department hadmet.

• There were processes in place to ensure the right personreceived the right radiological scan at the right time,however, we saw radiographers carrying outidentification checks with patients from memory, asthey did not have a computer in the scan room to checkagainst, and had to leave the scan room to check the

identification information given by the patient wascorrect. Between February 2016 and January 2017, thediagnostic imaging department notified CQC of eightincidents across all sites involving referral or patientidentification errors, resulting in unnecessary scanstaking place.

• We saw two radiographers checking patientidentification details entered on the scanner with thoseentered on the radiology booking system, to ensure thecorrect patient had been selected on the scannermonitor; however we did not see this recordedanywhere after the verbal checks were completed.

Mandatory training

• Staff received regular mandatory training updates, andthe trust had set a target for 90% of relevant staff acrossall sites to have competed all 12 mandatory trainingmodules. Subjects covered included manual handling,information governance, infection control and equalityand diversity awareness for all staff, with the addition ofsome specialist modules for medical staff whichincluded blood transfusion and prescribing. The trustmet its 90% target in three of the 12 modules formedical staffing and eight of the 12 modules for nursingstaff.

• Staff received updates on health and safety trainingthroughout the year. The health and safety departmentsent out briefings on a topic of the month. All staff wererequested to read these updates and sign to say theyhad done so. A form was required to be returned to thehealth and safety department to officially confirm staffwere updated.

• All staff were offered ‘awareness’ training to help themidentify and respond to patients with mental healthillnesses, learning disabilities, autism or dementia, andstaff had training in mental health awareness includedas part of their mandatory training. 96% of staff in thetrauma and orthopaedic outpatients department hadcompleted this training.

• The trust reported that at 31st October 2016 MentalCapacity Act (MCA) Awareness Act training had beencompleted by 100% of staff within outpatients

• Staff understood the difference between lawful andunlawful restraint practices and staff were aware how toseek authorisation for a deprivation of liberty.Deprivation of Liberty training had been completed by94.3% of staff in the outpatient departments.





• The Radiation Protection Advisor (RPA) was easilyaccessible for providing radiation advice and covered allCheltenham and Gloucester hospital sites. Staff coulddescribe how and why they would contact them, andunderstood their responsibilities to report certaindiagnostic imaging incidents to the Care QualityCommission (CQC) under the Ionising Radiation(Medical Exposures) Regulations 2000. Theseregulations help protect patients from unnecessaryharm caused by over exposure to ionising radiation.Staff could give us an example of an incident that hadbeen reported to the RPA and CQC, around themisidentification of a patient.

• The imaging services had appointed RadiationProtection Supervisors (RPS) in each clinical area. Theimaging service ensured that the ‘requesting’ of an X-rayor other radiation diagnostic test was only made byreferrers in accordance with IR(ME)R, and held lists ofapproved referrers for staff to check requests against.Staff told us this list was regularly reviewed andupdated, and we saw the current list.

• There were adequate signs and information displayed inthe diagnostic imaging department waiting areainforming people about areas and rooms whereradiation exposure took place. However, in nuclearmedicine we saw that the room used for storingunsealed radioactive sources (such as vials ofradiopharmaceuticals for injecting) was propped openand was not always occupied by a member of staff. Thiswas raised with senior staff member who immediatelyclosed and locked the door to prevent any accidental orunauthorised access by patients or other staff.

• The imaging service ensured that women who were ormay be pregnant always informed a member of staffbefore they were exposed to any radiation. For examplewe saw radiographers using the 28 day rule to confirmpregnancy before examinations were carried out (if apatient is unsure if they are pregnant and their lastmenstrual period is overdue, the radiographer orradiologist may consider postponing the examinationuntil pregnancy can be confirmed or ruled out). This wasin line with Royal College of Radiologists (RCR) bestpractice guidance, however we did not see any signsdisplayed in waiting areas or changing cubicles telling

patients to inform staff if they were or could bepregnant, which meant patients may not have told staffthey may have been pregnant before their x-rayexamination.

• There were local policies for the risk assessment andprevention of contrast induced nephropathy, and staffwere aware of these policies. Staff told us clear writteninformation was given to patients about hydrationbefore and after contrast examinations which we saw.These policies were in keeping with National Institutefor Health and Care Excellence (NICE) guidelines and theRCR standards for intravascular contrast agentadministration.

• There were not clear pathways and processes for theassessment of people within all outpatient clinics anddiagnostic imaging departments who were clinicallyunwell and required hospital admission. Staff coulddescribe how to summon help by dialling 2222,however, some staff were unsure of their responsibilitiesin a resuscitation situation, and one member of staffsaid they would not attempt resuscitation until thecrash team arrived to take charge of the situation. Allstaff in diagnostic imaging had undertaken basic lifesupport (BLS) training, but had not been trained in theuse of the automatic defibrillators which were found onmost resuscitation trolleys in the outpatient anddiagnostic imaging departments.

• In the trauma and orthopaedic department, staff told usthe digital dictation system had crashed, losing manyclinic letters. Staff said an investigation had shown thecause was IT failure, however an unknown number ofletters had been lost, and they did not know whichpatients had been affected until they attended for theirfollow up appointments. Staff told us each patientidentified was reported as an incident via the trustselectronic reporting system. However; staff wereunaware if the issue was on the directorate risk register.

• Most staff demonstrated understanding of consent anddecision making requirements of legislation andguidance, including the Mental Capacity Act 2005 andthe Children Acts 1989 and 2004. The process for seekingconsent was monitored by an audit programme whichshowed 82% of notes audited had documentedevidence of consent.

• Patients were adequately supported to make decisions,and a patients’ mental capacity to consent to care ortreatment was assessed during clinic appointments andthis assessment was recorded in the patient’s notes.




When patients lacked the mental capacity to make adecision, staff made ‘best interests’ decisions and wereaware how to do this in line with legislation. Forexample, staff we spoke with in the pain managementservice knew how to access on site liaison psychiatry ifthey were concerned about risks associated with apatient’s mental health.

• There were appropriate risk assessments in place forthose who needed them on account of issues relating totheir mental health, learning disabilities, autism ordementia diagnoses and staff were aware of them,however we saw an out of date mental health riskassessment form in the trauma and orthopaedicoutpatient department that had not been updatedsince 2014.

Nursing staffing

• Staffing levels and skill mix were planned and reviewedso that people were protected from harm. At GloucesterRoyal Hospital, the outpatient department was staffedby 17.9 (53%) unqualified staff, and 15.7(47%) qualifiedstaff, which was better than the trust’s target staffingratio.

• Staff worked across all areas of the outpatientdepartment, and covered additional hours through thehospital bank staff system. We saw that no agency staffwere used on the rotas we reviewed.

• Across both hospital sites, the outpatient departmentshad a sickness level of 4.9% in September 2016, whichwas above the trust target of 3%, however somedepartments were meeting this target, such as the ENTdepartment at Gloucester Royal Hospital wherebetween January 2016 and December 2016 thedepartment had an average sickness rate of 3%.

• The highest level of sickness across both hospital siteswas in the orthodontics departments which was 8.2%.

Allied healthcare professional staffing

• Staffing levels and skill mix were planned and reviewed,however actual staffing levels were often less thanplanned staffing. Staffing levels for the departmentshowed between 40 to 41 planned qualified staff(radiographers) and six planned non-qualified(radiography assistants) on a week day and 18 qualifiedand four non-qualified on a weekend. Actual staffinglevels for the department showed the planned staffingwas frequently not met by between one to six staff forqualified staff, and one to two for non-qualified staff.

One week day showed there were 27 qualified staffagainst a planned establishment of 41 staff. Anotherweekend day showed a shortfall of five staff against aplanned establishment of 18 qualified staff. Staff told ussome weekend shifts were understaffed and had led toincreased waits for non-urgent patients.

• At the time of our inspection, the diagnostic imagingdepartment across both sites, had seven band 5radiographer vacancies, and seven band 6 radiographervacancies, and staff said some shifts were often down amember of staff. Managers told us of an on-goingrecruitment plan to engage with universities toencourage newly qualified staff to apply to the hospitalto help fill the band 5 positions.

• Data supplied for both hospital sites showed diagnosticimaging had a sickness rate of 3.6% in September 2016,which was above the trust target of 3%, and a staffturnover rate of 1.7%.

Medical staffing

• The diagnostic imaging department currently had 5.5whole time equivalent vacancies for radiologists, withan advert currently live. Staff told us radiographers hadbeen used to help clear the reporting backlog, as theexisting radiologists did not have capacity to clear it,and meet current reporting targets.

• In cardiology, we were told a consultant had recently leftdue to health problems, and had not been replacedwhich was contributing to capacity and flow problemsin the service.

• Currently, there were four full time cardiologyconsultants and one locum consultant based atGloucester Royal Hospital, however, the locum was dueto finish in March 2017, and staff were unaware of anyplans to extend their contract.


• Potential risks such as seasonal fluctuations in demand,the impact of adverse weather, or disruption to staffingwere taken into account when planning services. Wesaw an up to date business continuity plan whichcovered adverse weather arrangements for staff tofollow to ensure essential treatment could still becarried out.

• There were reliable arrangements in place to respond toemergencies and major incidents. For example thetrauma and orthopaedic outpatient department had amajor incident plan in place and told us which patients




would be evacuated in case of an emergency situation,a list of all staff to be called and a lock down policy. Itwas not possible to lock down the whole of thedepartment but certain areas were lockable from theinside. We visited the pain management and psychologydepartment and were shown a room which could belocked down in case of an incident.

• There were effective arrangements in place in case of aradiation or radioactive incident occurring and staffcould explain how they would contain a spillage of aradiopharmaceutical, and knew who to contact andhow to report the incident.

Are outpatient and diagnostic imagingservices responsive?


We rated responsive as requires improvement because:

• The hospital was not meeting the 62 day target forcancer patients.

• The diagnostic imaging department had a reportingbacklog of 19,500 films and was not meeting its five dayreporting target for accident and emergency x-rays.

• A significant typing backlog was causing delays insending out patient letters impacting on patient safety.

• Implementation of new IT systems had impacted onwaiting lists as some specialties could not see livewaiting lists.

• The trust was not meeting referral to treatment target inall specialities.

However;

• Rapid access assessment clinics were provided in somespecialities, and some clinics were performing airwayassessments via Skype.

• The hospital had introduced a new waiting listvalidation process to discharge patients on-going followup care to community based services such as GPs.

• A project placing therapists on wards had helpedincreased patient discharges, and radiographersattended ward briefings to identify inpatients waiting forscans.


• Information about the needs of the local populationwas used to inform how services were planned anddelivered. Commissioners and local GPs had beeninvolved in developing a process for reviewing allpending and follow up patients. In June 2016, local GPshad begun to identify patients who were currently underthe care of the hospital, who could be discharged backto community services such as community hospitalsand GP surgeries for their on-going care and follow up.This had begun to free up more capacity in the hospitalclinics to accept new patients.

• Where patient’s needs were not being met, this wasidentified and used to inform the planning anddevelopment of services. For example, it had beenidentified that some services were not planned in a waywhich met people’s needs, and some patients wereremaining on follow up lists for too long after theirtreatment. This in turn was preventing the services fromseeing new patients. For example, in dermatologyfollowing the removal of some non-cancerous skinlesions, some patients were returning to the hospital forwound checks. Staff had identified this group of patientsas being suitable to have wound checks carried out inGP surgeries, and were working to develop a care planfor GPs to follow when patients were discharged fromthe dermatology service.

• Services were planned and delivered to take account ofthe needs of different people. For example staff told usof a consultation which was on-going to engage patientsin the planning of future cardiology services. Patientswere invited to share their views through online surveysor to share their stories by email.

• The therapies department had increased the numbersof occupational therapists and physiotherapists onwards over a five day period at Christmas. The teamshad reported they had been able to discharge betweentwo to three additional patients each day as a result,although no formal collation of this data had takenplace at the time of our inspection.

• The services tried to provide choice and continuity ofcare, and several patients told us they had used the‘choose and book system’ to book their clinicappointment, which offered a selection ofappointments for them to choose from. One patient toldus that where changes had been made to the clinic, inparticular the doctor they were seeing, this had beencommunicated to them in a letter keeping theminformed.




• Some clinics in thoracic medicine used online videocalls as an alternative to face to face appointments.Patients attended for blood tests at the hospital andreceived an airway assessment from an anaesthetistbased in another large hospital in Bristol, which meantpatients did not have to travel to see the doctor inperson.

• The environment of the outpatient clinics anddiagnostic imaging department was not alwaysappropriate and patient centred. For example we sawchanging cubicles in waiting areas, and saw patients satin waiting areas in hospital gowns compromising theirprivacy and dignity.

• The facilities for children in waiting rooms were notalways adequate. For example in the ophthalmologydepartment children and adults waited in the sameareas, and there was a small section of children books,but no toys.

• Patients were able to locate the outpatient anddiagnostic imaging departments because they wereclearly signposted within the hospital and there werevolunteers available to help. However, in ophthalmologywe saw the signage was not adapted for visuallyimpaired patients, and one patient told us it wasdifficult to read.

• Patients told us information was provided to thembefore their appointments, which included a hospitalmap and directions, their consultant’s name andparking and travel information.

• There were no dedicated quiet areas where patientscould wait without being forgotten if they found busyenvironments distressing. Staff told us in thedermatology and trauma and orthopaedic outpatientclinics, if the main waiting rooms were too stressful anenvironment they would access empty clinic rooms toaccommodate patients with mental health conditions,learning disabilities, autism or dementia. Receptionistsleft a note on the patient’s records to say where theywere waiting.

Access and flow

• Care and treatment was prioritised for people with themost urgent needs, and rapid access outpatient clinicswere available each day for patients who required chestpain assessment, urgent ophthalmology assessment,

ear nose and throat (ENT) appointments or access totrauma and orthopaedic clinics. A telephone triagesystem in ophthalmology helped staff identify patientswho needed to attend accident and emergency.

• Between April 2015 and March 2016, the follow-up tonew rate for Gloucestershire Royal Hospital was lowerthan the England average. This meant the trust wasseeing more new patients when compared with the restof the hospitals across England.

• Between November 2015 and October 2016 the trust’sreferral to treatment time (RTT) for non-admittedpathways has been worse than the England overallperformance. The latest figures for October 2016showed 82.5% of this group of patients were treatedwithin 18 weeks versus the England average of 89.4%.Whilst the trust was following the national trend ofdecline in this measure, it was declining at a faster ratethan the England average. However, of out of the 16specialties reported, six were meeting the RTT. Theseincluded ophthalmology, trauma and orthopaedics,general medicine, general surgery and gastroenterology.

• Between November 2015 and October 2016 the trustreferral to treatment time (RTT) for incomplete pathwayshas been overall better than the England overallperformance but worse than the operational standardof 92%. The latest figures for October 2016 showed89.9% of this group of patients were treated within 18weeks versus the England average of 90.1%. The trust’sperformance had followed the England average untilMay 2016 when performance started to decline overtime. However, despite this decline the trust’sperformance was better than the England average inSeptember and October 2016. Of the 17 specialitiesreported, 11 were meeting or exceeding the RTT. Theseincluded, ophthalmology, dermatology,gastroenterology, trauma and orthopaedics and generalsurgery. For specialties not meeting their RTT targets,recovery plans were drawn up which included specialityspecific measures to improve their performance. In oralsurgery outpatients, 983 patients waited over 18 weeksfor treatment. The trust identified the shortfall incapacity, and had recruited a speciality doctor and anadditional consultant to provide the additional capacityneeded.

• The waiting times for patients needing cancer treatmentwere described in relation to the ‘cancer wait’ targets setby NHS England. The trust was performing worse thanthe 93% operational standard for people being seen




within two weeks of an urgent GP referral betweenOctober 2015 and September 2016. However, since April2016, this had begun to improve, and during ourinspection, we saw data which showed the trust hadmet the 93% target in October and November 2016, buthad declined slightly in December to 92.5%. The overallsituation had improved since our last inspection.

• Between October 2015 and September 2016 the trustwas consistently performing better than the 96%operational standard for patients waiting less than 31days before receiving their first treatment following adiagnosis (decision to treat). However, the trust wasperforming worse than the 85% operational standardfor patients receiving their first treatment within 62 daysof an urgent GP referral. This was similar to what wasfound on the previous inspection.

• Between November 2015 and October 2016 thepercentage of patients waiting more than six weeks fortheir test or scan was higher than the England averagefor five of the twelve months.

• The diagnostic imaging department across all sites, hada reporting backlog of 19,500 plain films, which it wasworking to reduce, and provided weekly updates to theboard. We were told the department had employed anumber of reporting radiographers to reduce thebacklog, which had been over 40,000 films in September2016. The department had prioritised outstanding CTand MRI scans, which had allowed the plain film backlogto rise. At the time of our inspection there were 250 CTscans outstanding, and 270 MRI scans.

• Clinicians in the diagnostic imaging departmentreminded referrers of their responsibilities for reviewingand documenting findings from X-rays they requested,which insured no images were going un-reviewed by aclinician. The clinical lead for diagnostic imaging had aproposal to clear all of the outstanding reporting, whichrequired funding approval from the board. If this wasunsuccessful, the department was planning to auditpatient notes to assess if referrers were documentingtheir findings, which is a requirement of IR(ME)R 2000and an extra assurance of patient safety.

• The diagnostic imaging department had set a target forall examinations to be reported within five days. Datasubmitted for October 2016 showed that 87.2% ofexaminations were reported within five days and 12.8%over five days. Accident and emergency examinationshad a three day target for report turnaround, which thedepartment was meeting for CT, MRI, Nuclear medicine,

ultrasound and fluoroscopy examinations, however,57.8% of plain film X-rays were waiting over five days fora report, which meant patients were waiting longer toget their official report, which may impact on theiron-going treatment.

• Action was taken to minimise the time people have towait for treatment or care. For example in diagnosticimaging in October 2016, 53% of outpatients attendedfor their examinations within two weeks of a referralbeing accepted, and radiologists worked to verifyreports within 24 hours to minimise delays in sendingout results. In October 2016, 98.2% of were verifiedwithin 24 hours.

• The diagnostic imagining department was sendingradiographers onto the wards to attend morningbriefings to help identify patients who were waiting forscans. In order to accommodate more inpatient andemergency scans at Gloucester Royal Hospital, routinepatients were being sent appointments to have theirscans at Cheltenham General Hospital, and staff told usmost patients were happy to do this once it wasexplained why.

• The cardiology department had a typing backlog of1114 letters in December 2016. Staff told us medicalsecretaries were spending an increasing amount of theirtime speaking with patients and GPs over the phone,who were chasing clinic letters which was in turnaffecting their ability to work through the typingbacklog. Senior staff told us they had been givenauthority to outsource some typing in December 2016,but this had not yet happened. Senior staff hadescalated the lack of action to the executive board theweek before the CQC inspection. The executive boardreaffirmed the outsourcing should take place as soon aspossible, and senior staff were waiting for this tobe completed by managers. Data submitted since ourinspection showed the trust was planning to outsourcereporting from February 2017, and had made acontingency available to each specialty to use theoutsourcing company in future to maintain their typingbacklogs.

• Bookings for most outpatient clinics were made throughthe offsite central bookings office, with the exception ofsome specialist clinics which were booked by theconsultants. The trust had recently introduced a newcomputer system to oversee all aspects of patient careincluding bookings. Staff told us the system had left




them unable to view some waiting lists, and staff wereusing data from the end of November to bookappointments. Senior staff told us the next role out ofthe system would rectify some of these issues.

• Care and treatment was only cancelled or delayed whenabsolutely necessary. Between June 2016 andSeptember 2016, the trust cancelled between 3 - 3.2% ofall outpatient appointments across all sites with lessthan six weeks’ notice, and between 4.9 – 6.4% of clinicswith over six weeks’ notice. The most frequent reasonsfor these cancellations were clinicians’ annual leave andthe junior doctor strike.

• Patients told us that cancellations were explained tothem, and they were supported to access care andtreatment again as soon as possible. For example, onepatient told us they had received a phone call about acancelled appointment, but the member of staff hadmade sure the patient had a new appointment at a timeto suit them, before they had finished the call.

• Patients told us that the waiting times for appointmentswere always communicated, and this was echoed onthe trust website in its information about the outpatientdepartment.

• We saw that some clinics usually ran on time. During ourinspection we saw staff kept patients informed duringclinic sessions using whiteboards where they recordedthe individual delays for each clinic. We saw how staff inthe outpatient departments apologised to patientswhen their appointments were delayed.

• The diagnostic imaging department recorded the timethat patients were kept waiting once they arrived in thedepartment. Data collected between May 2016 andOctober 2016 indicated that patients for plain filmimaging were being seen on average within six to eightminutes of booking into the department. Patients forComputed tomography waited on average between48-50 minutes and nuclear medicine patients between76-110 minutes, however, this was due to the complexityof the scans which often required patients to wait for aset period of time prior to their scan.

• The trust did not record the time that patients were keptwaiting if they required an additional appointment forexample diagnostic or imaging, and reported that datarecorded to try and capture this had been unreliable.

• The outpatient service rates of non-attendance forappointments were below the England average for

Gloucestershire Royal Hospital between April 2015 andMarch 2016. Action had been taken to reduce this rate,such as using text messages to remind patients of theirupcoming appointments.


• The trust ensured appropriate support was available forbariatric patients. For example in the diagnostic imagingdepartment, equipment had been purchased withbariatric patients in mind. Several CT and MRI scannershad wider bores and larger weight limits on tables,which meant services could be readily accessed by thisgroup of patients.

• The outpatient departments did not arrangeappointments so new patients were given time to askquestions and staff told us this was often the reasonclinics fell behind, however, the trust did not collect antdata to support this.

• In the main reception for outpatient clinics and thetrauma and orthopaedic outpatients department,patients were not always able to speak to thereceptionist without being overheard.

• Support for people with learning disabilities wasavailable. For example we saw leaflets and signs for staffand patients which contained details of the learningdisabilities liaison nurse team, and staff we spoke withwere aware of this team, and knew how to contact themfor advice.

• Staff also told us they advised patients and theirrelatives who had learning disabilities or were living withdementia to attend the clinic ahead of theirappointment time, and when patients did this, theyattempted to slot them into lists early.

• Translation services were always readily available ifrequired. Staff told us that the booking office would prebook translators, if an occasion arose that a translatorwas not pre booked then a telephone translation servicewas used.

• Staff told us about occasions when reasonableadjustments were made so that people with a disabilitycould access and use the outpatient and diagnosticservices. For example, staff in the dermatologyoutpatient clinic told us that they had used stories in theform of a picture book to explain what happened in ahospital clinic.

• Hearing loops were installed in clinic reception areasand the main outpatient reception waiting area to assistpatients with hearing loss.





• Patients knew how to make a complaint or raiseconcerns and told us they felt confident to speak upabout concerns if necessary. We saw leaflets displayedin most clinical areas about the complaints process andthese were available in different languages and easyread formats.

• Patients who we spoke with said they would be happyto raise a complaint, but none had felt the need to doso.

• Between November 2015 and October 2016 there were390 complaints about the outpatient departments

across all sites. The trust took an average of 36 workingdays to investigate and close complaints, which was notin line with their complaints policy, which stated 95% ofcases should be responded to within 35 working days.

• Across all sites the most complained about areas wereappointments with 99 (25.3%) complaints, and clinicaltreatment with 77 (19.7%) complaints.

• Gloucestershire Royal Hospital received 249 complaintsbetween November 2015 and October 2016 about theoutpatient departments. The most complained aboutarea was appointments, which accounted for 66complaints (27%) of all complaints received.




Outstanding practice

• The diagnostic imaging department sentradiographers onto wards to liaise with staff to identifyinpatients who were waiting for scans, in order to helpspeed up treatment and ultimately discharge.

• The therapies department had placed occupationaltherapists and physiotherapists on wards overChristmas to support and speed up patient dischargesduring a period of high pressure.

• The inpatient specialist palliative care team had wonan annual staff award the trust - patient’s choice award2016. This was from patients and others whorecognised the NHS staff who had made a difference totheir lives.

• The consultant in the specialist palliative careteam was part of a multi-disciplinary team who hadwon the national Linda McEnhill award 2016. Theaward was recognition by the Palliative Care of Peoplewith Learning Disabilities professional network ofexcellence in end of life care for individuals withlearning disabilities. Work included improving howdifferent teams worked better together.

• The development of a training package for midwivesto enable them to administer flu vaccinations to at riskwomen had meant that a high number of women whowould otherwise have not had the flu vaccine hadreceived it.

Areas for improvement

Action the hospital MUST take to improve

• Review processes to monitor the acuity of patients toensure safe staffing levels.

• Ensure wards are compliant with legislation regardingthe Control of Substances Hazardous to Health(COSSH).

• Review processes for ensuring effective cleaning ofward areas and equipment and patient waiting areas.

• Review the governance and effectiveness of care andtreatment through national audits.

• Ensure patient records are kept securely at all times.• Ensure equipment is replaced to ensure safe diagnosis

and treatment.• Ensure the medical day unit is suitable for the delivery

of care and protects patients dingy and confidentiality.• Ensure all staff are trained and understand their

responsibilities in a resuscitation situation.• Ensure resuscitation equipment is readily available

and accessible to staff.• Ensure steps are taken to reduce the current typing

backlog in some specialities.• Ensure specialities have oversight of all of their waiting

lists.• Ensure that all information related to patients’ mental

capacity and consent for ‘Do Not AttemptCardio-Pulmonary Resuscitation’ (DNA CPR) isavailable in patient records.

• Ensure trust staff comply with all the requirements ofthe Mental Capacity Act (2005).

• Ensure the emergency department is consistentlystaffed to planned levels to deliver safe, effective andresponsive care.

• Review support staff functions to ensure theemergency department is adequately supported.

• Ensure all staff are up-to-date with mandatorytraining.

• Ensure patients arriving in the emergency departmentreceive a prompt face-to-face assessment by a suitablyqualified clinician.

• Improve record keeping so that patients’ recordsprovide a contemporaneous account of assessment,care and treatment.

• Ensure patients in the emergency department receiveprompt and regular observations and that earlywarning scores are calculated, recorded and actedupon.

• Ensure the mental health assessment room in theemergency department meets safety standardsrecommended by the Royal College of Psychiatrists.

• When using Kemerton and Chedowrth Suite forinpatients, provision must be made for the cleaning ofthe units at weekends and to provide patients withclean water jugs and drinks.

Outstandingpracticeandareasforimprovement

Outstanding practice and areas for improvement


• Ensure emergency resuscitation trolleys are checkedand have guidelines attached according to bestpractice guidance and in line with trust policy.

• Ensure the safe management of medicines at all times,including storage, use and disposal and the checkingand signed for controlled drugs. Ensure all drugstorage refrigerator temperatures are checked and theresults recorded daily. Additionally if the temperaturesfall outside of the accepted range action is taken andthat action recorded.

• Ensure patient group directives are up to date andconsistent in their information.

• Ensure women attending the triage unit within thematernity service are seen within 15 minutes of arrival.

Action the hospital SHOULD take to improve

• The medical service should collect information aboutmortality and morbidity (M&M) meetings electronicallyacross all services to ensure an audit trail ismaintained and outputs governed.

• Ensure all staff are compliant with efficientdecontamination of hands on entering wards.

• Ensure emergency equipment (including resuscitationtrolleys) is checked daily in line with trust policy andnational guidance.

• Review processes to recognise and respond to blankboxes on prescription charts to make sure patientsreceive medicines as prescribed.

• Review the process to assess risks to patients andensure a management plan is in place.

• Review process to comply with VTE assessment in linewith trust policy and national guidelines.

• Ensure treatment pathways are reviewed and updateto ensure best evidence-based treatment.

• Ensure all staff receive yearly appraisals in line withtrust policy.

• Review process to ensure patients are reviewed by aconsultant within 14 hours of admission in line withthe London Quality Standards (2013).

• Review processes to ensure compliance with theaccessible information standards.

• Ensure areas used to admit patients in times of highorganisational pressures are suitable and staffed toensure safe care and treatment of patients.

• Ensure effective monitoring of clinical improvementand audits, including compliance with accurate andtimely NEWS assessments.

• Ensure timely response to complaints in line with trustpolicy.

• Ensure an up to date list of all practitioners underIR(ME)R is maintained.

• Ensure there are sufficient numbers of staff withappropriate skills and experience on each shift indiagnostic imaging.

• Ensure identification procedures in diagnostic imagingare robust and recorded.

• Ensure all staff are up to date with mandatory training.• Ensure all patient’s referral to treatment times do not

exceed national targets including cancer wait targets.• Ensure steps are taken to reduce the current reporting

backlog.• Ensure diagnostic imaging examinations are reported

within target for the accident and emergencydepartment.

• Ensure steps are taken to monitor and reduce thenumbers of temporary notes in use.

• Ensure all hazardous chemicals and cleaning productsare securely stored.

• Review facilities for staff to take breaks and makedrinks away from clinical areas

• Ensure staff can effectively trace patient recordsthrough the hospital.

• Ensure disabled toilets have sufficient alarm systems.• Ensure all risk identified relating to the provision of

end of life care is included on a risk register.• Ensure the training needs analysis for general staff on

wards related to end of life care is completed by thetrust end of life care strategic group

• Consider involving specialist palliative care team andsupport teams in major incident plan practices orexercises.

• Review the signage and consider if the system of using‘white rose’ symbols to assist location of trustmortuaries is effective

• Consider the availability of family rooms associatedwith wards for overnight accommodation for thoseclose to patients at end of life.

• Ensure staff in specialist palliative care team are ableto use the results of the safety thermometerinformation in relation to patients receiving end of lifecare.




• Continue to work in collaboration with partners andstakeholders in its catchment area to improve patientflow within the whole system, thereby taking pressureoff the emergency department, reducing crowding andthe length of time patients spend in the department.

• Ensure the emergency department is supported by thewider hospital and that there is more engagementfrom specialties in addressing the risks associated withpatient flow.

• Ensure the workload pressures and impact on staffwellbeing, associated with crowding in the emergencydepartment, are understood, identified on the riskregister and that staff are supported as appropriate.

• Ensure all staff within the specialities is aware of NeverEvents and the learning needed to prevent areoccurrence.

• Continue to make improvements with the reduction ofsurgical site infection rates.

• Review the pre admission clinic area for comfort andsuitability

• Provide resuscitation equipment for the pre admissionunit to ensure if a patient collapsed, they receive thecorrect care in a timely manner.

• Review the equipment in the pre-admission unit toensure it meets the needs of the service.

• Patient group directions (PGDs) should be reviewed asthey were out of date and the correct authorisationsignatures should be included.

• Continue to work on your action plan to address theshortfalls identified in the mortality outliers.

• Review the lack of 24-hour emergency theatre toensure no patients will be put at risk.

• Continue to address issues resulting from the newcomputer system.

• Improve the number of staff appraisals completed.

• Reduce the number of patients who have theiroperation cancelled on the day of surgery, and reducethe number of patients not rebooked within 28 days.

• Ensure emergency trolleys on the neonatal andchildren’s units have a system that easily highlights ifan emergency trolley has been tampered withbetween routine checks.

• Support all children’s services to contribute toinfection prevention and control audits so that risk canbe accurately assessed.

• Consider options of protecting children’s safety whenwaiting for appointments in parts of the hospital thatare not dedicated to paediatrics.

• Continue with strategies to maintain staffing levelsthat meet national guidelines.

• The trust should ensure electronic systems in place,especially for community midwives, enable them toinput data in a timely way. Additionally they shouldhave mobile phones with better connectivity to ensurethey receive their messages in a timely way.

• The trust should ensure that all inpatient venousthromboembolism (VTE) risk assessments arecompleted.

• The trust should ensure that senior house officerequivalent doctors attended PROPMT skills and drillstraining.




Action we have told the provider to takeThe table below shows the fundamental standards that were not being met. The provider must send CQC a report thatsays what action they are going to take to meet these fundamental standards.

Regulated activity

Diagnostic and screening procedures

Treatment of disease, disorder or injury

Regulation 15 HSCA (RA) Regulations 2014 Premises andequipment

Health and Social Care Act 2008 (Regulated Activities)Regulations 2014 regulation 15 Premises and equipment

15 – (1) (a) All premises and equipment used by theservice provider must be clean.

The fabric of the building did not always ensure efficientcleaning could be carried out. The premises used for thedelivery of services in ophthalmology outpatients werevisibly unclean, with dirty fans in use in clinicalprocedure rooms.

Staff did not always comply with legislation regardingthe Control of Substances Hazardous to Health (COSHH).

When Kemerton and Chedworth Suite were opened atweekends, there was no provision for cleaning of the unit

15 – (1) (c) All premises and equipment used by theservice provider must be suitable for the purpose forwhich they are used

The medical day unit comprised of mixed sex bays werecramped. Patients had very little space between chairs,several patients had visitors with them and this madethe bay even more cramped and did not ensure patient’sdignity or confidentiality

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices


The mental health assessment room did not comply withsafety standards recommended by the Royal College ofPsychiatrists

Regulated activity

Diagnostic and screening procedures

Treatment of disease, disorder or injury

Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

17 (2) (a) There must be systems and process in place tomonitor and improve the quality of and safety ofservices.

The processes and systems used to monitor and processthe number of outstanding clinic letters were noteffective, and several specialities had significantbacklogs of typing.

There was no oversight of competency for the use ofsyringe drivers.

The medical service did not consistently participate inand review the effectiveness of care and treatmentthrough participation in national audits.

17 (2) (b) Assess, monitor and mitigate the risks relatingto the health, safety and welfare of service users andothers who may be at risk which arise from the carryingon of the regulated activity;

The processes and systems in place to identify andassess risks to the health and safety of people who usedthe services were not effective. The lack of oversight ofthe backlog of pending and follow up waiting lists placedpatients at risk of harm due to increased delays intreatment and assessment.

Regulation




17 (2) (c) maintain securely an accurate, complete andcontemporaneous record in respect of each service user,including a record of the care and treatment provided tothe service user and of decisions taken in relation to thecare and treatment provided;

People who used the services were not protected fromthe risk associated with unauthorised access toconfidential patient records. Patient records were notsecurely kept at all times.

Documentation relating to patients’ mental capacity andconsent was not always complete or immediatelyobvious in ‘do not attempt cardio-pulmonaryresuscitation’ (DNA CPR) records.

Regulated activity

Treatment of disease, disorder or injury Regulation 12 HSCA (RA) Regulations 2014 Safe care andtreatment

12 (2) (a) assessing the risks to the health and safety ofservice users of receiving the care or treatment:

There were some concerns regarding the transfer ofpatients receiving intravenous therapy during thetransfer. These transfers required a nurse escort for thetransfer and if this could not be arranged, we were toldthe intravenous therapy would be discontinued for theduration of the transfer

12 (2) (c) ensuring that persons providing care ortreatment to service users have the qualifications,competence, skills and experience to do so safely;

The systems and processes in place to protect patientsfrom harm in emergency situations were not effective.Staff were unsure of their responsibilities in a

Regulation




resuscitation situation and did not feel sufficientlytrained or confident to undertake immediate emergencycare, and resuscitation equipment was not readilyavailable, or easily located in all clinical departments.

Not all staff were up to date with mandatory training.

Risks to patients were not always mitigated because staffdid not follow plans and pathways. Patient observationswere not consistently undertaken with the requiredfrequency in the emergency department to ensure thatany deterioration in a patient’s condition was identified.Risk assessments in respect of skin integrity andnutrition and hydration were not consistentlyundertaken.

Patients arriving in the emergency department did notalways receive prompt, face to face initial assessment bya clinician.

Regulated activity

Treatment of disease, disorder or injury Regulation 11 HSCA (RA) Regulations 2014 Need forconsent

(1) Care and treatment of service users must only beprovided with the consent of the relevant person.

(3) If the service user is 16 or over and is unable to givesuch consent because they lack capacity to do so, theregistered person must act in accordance

with the 2005 Act*.

Explanations for the reason for the decision to withholdresuscitation attempts were not consistently clear.

Regulation




Records of resuscitation discussions with patients andtheir next of kin or of why decisions to withholdresuscitation attempts were not discussed or were notdocumented.

Regulated activity

Treatment of disease, disorder or injury Regulation 18 HSCA (RA) Regulations 2014 Staffing

(1) Sufficient numbers of suitably qualified, competent,skilled and experienced persons must be deployed inorder to meet the requirements of

this part.

(2) Persons employed by the service provider in theprovision of a regulated activity must—

(a) receive such appropriate support, training,professional development, supervision and appraisal asis necessary to enable them to carry out the duties theyare employed to perform,

(c) where such persons are health care professionals,social workers or other professionals registered with ahealth care or social care regulator, be enabled toprovide evidence to the regulator in questiondemonstrating, where it is possible to do so, that theycontinue to meet the

professional standards which are a condition of theirability to practise or a requirement of their role.

There were not always sufficient numbers of suitablyqualified, skilled and experienced nursing staff in theemergency department.

There were insufficient numbers of senior medical staffemployed at night in the emergency department toensure patients received timely diagnosis and treatment.

Regulation




Support staffing in the emergency department wasinadequate, which meant clinical staff were frequentlyrequired to undertake administrative, cleaning andportering tasks.




Gloucestershire Royal Hospital - Care Quality Commission

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