gloucestershire hospitals nhs foundation trust · assessment or medical treatment for persons...

20171116 900885 Post-inspection Evidence appendix template v3

Gloucestershire Hospitals NHS

Foundation Trust

Evidence appendix Trust HQ

Alexandra House

Sandford Road

Cheltenham, Gloucestershire, GL53 7AN

Tel: 0845 422 2222

www.gloshospitals.nhs.uk

Date of inspection visit:

9 October to 15 November 2018

Date of publication:

7 February 2019

This evidence appendix provides the supporting evidence that enabled us to come to our judgements of the quality of service provided by this trust. It is based on a combination of information provided to us by the trust, nationally available data, what we found when we inspected, and information given to us from patients, the public and other organisations. For a summary of our inspection findings, see the inspection report for this trust.

Facts and data about this trust

Background Information

Gloucestershire Hospitals NHS Foundation Trust is one of the largest in the country. It was formed

from Gloucestershire Hospitals NHS Trust, which was established following a reconfiguration of

health services in Gloucestershire in 2002, and received authorisation on 1 July 2004.

The trust provides a full range of acute and elective hospital services from two large district

general hospitals, Cheltenham General Hospital and Gloucestershire Royal Hospital. Maternity

Services are also provided at Stroud Maternity Hospital. Trust staff also provide outpatient clinics

and some surgery from community hospitals throughout Gloucestershire.

Gloucestershire Royal Hospital provides general hospital services. Gloucestershire Royal Hospital

has a 24-hour Emergency department and has a new state of the art Children's Centre. A £29

million women’s centre opened on the Gloucestershire Royal site in January 2011. The hospital

also has a range of operating theatres, inpatient wards and provides outpatient services from a

newly renovated and dedicated outpatient department.

Cheltenham General Hospital provides general hospital services. Cheltenham General

Hospital has state-of-the-art critical care facilities and is home to the specialist Oncology Centre as

well as breast screening facilities at the Thirlestaine Road clinic. This hospital also has an

Interventional Radiology operating theatre, surgical robot used in treating prostate cancer and

provides a wide range of outpatient services. A £250k newly refurbished Cheltenham General

Hospital Birth Centre opened in August 2011 and is located on site.


The trust also provides services from community hospitals in Stroud, Berkeley Vale, Forest of

Dean, Tewkesbury and North Cotswolds, Cirencester, Evesham and Ross on Wye and there is a

midwife led birth centre in Stroud.

Facts, data and patient numbers

The area served covers both urban and rural communities. Whilst also covering some highly

affluent areas others within the county fall within the 10% most deprived areas in England. The

trust serves a diverse population of around 628,000, and over the course of a year, the trust

provides:

17,000 Planned Inpatient Admissions 62,000 Emergency Inpatient Admissions 74,000 Day Case Admissions 800,000 Consultant Outpatient attendances 140,000 A&E attendances at Cheltenham General and Gloucestershire Royal Hospitals

Of all admissions to trust hospitals (excluding day case work), 73% come in through the

emergency route.

The trust has 960 beds and employs approximately 8,000 staff including 895 medical staff, 2,340

Nursing/midwifery staff, 405 Allied Healthcare Professionals, 806 Healthcare Assistants, and 237

Scientific staff. Estates are provided by Gloucestershire Managed Services and employs 629 staff.

Financial position

The trust has a £500m annual operating income.

The financial position at the trust had improved in the year 2017/18 after high levels of savings. As

at Month 6, the Trust reported to its Board an operational deficit of £16.7m. This is a favourable

variance to budget and NHS Improvement Plan of £0.2m. The most likely forecast outturn deficit

for the Trust was reported to be £22.7m which is an adverse variance of £3.8m against the Control

Total deficit of £18.8m (including Provider Sustainability Funding). This reflects risks materialising

including clawback of Agenda for Change funding for the Trust’s wholly owned subsidiary.

At the time of the inspection NHS Improvement lifted financial special measures status from the

trust.

Acute hospital sites at the trust

A list of the acute hospitals at the trust is below.

Name of acute

hospital site Address


Details of any specialist

services provided at the

site

Cheltenham General

Hospital

Sandford Road, Cheltenham, GL53

7AN

Assessment or medical treatment for persons detained under the 1983 Act

Diagnostic and screening procedures

Maternity and midwifery services

Services for everyone Surgical procedures Treatment of disease,

disorder or injury

Cirencester Hospital Tetbury Road, Cirencester, GL7 1UY



disorder or injury

Gloucestershire Royal

Hospital

Gloucestershire Royal Hospital,

Gloucester, GL1 3NN

Assessment or medical treatment for persons detained under the 1983 Act




disorder or injury

Lydney and District

Hospital Grove Road, Lydney, GL15 5JE

Services for everyone Surgical procedures

Stroud General

Hospital Trinity Road, Stroud, GL5 2HY


Services for everyone Surgical procedures

Stroud Maternity

Hospital (Stroud

Maternity Unit)

Field Road, Stroud, GL5 2JB



Caring for children (0 - 18yrs)

Caring for adults under 65 years of age.


Tetbury Hospital Malmesbury Road, Tetbury, GL8 8XB

Services for everyone Treatment of disease,

disorder or injury

Tewkesbury Hospital Barton Road, Tewkesbury, GL20 5QN Services for everyone Surgical procedures

(Source: Trust Website)

What people who use the trust’s services say

The Friends and Family Test (FFT) was launched in April 2013. It asks people who use services

whether they would recommend the services they have used, giving the opportunity to feedback

on their experiences of care and treatment.

The trust scored below the England average for recommending the trust as a place to receive care

from August 2017 to July 2018.

ce: Friends and Family Test)

(Source: Friends and Family Test)

In the most recent FFT data, Gloucestershire Royal Hospital’s results (percentage of patients who

would recommend the hospital) was 92% for outpatients, 89% for inpatients and 83% for urgent


and emergency care. Cheltenham General Hospital’s results (percentage of patients who would

recommend the hospital) was 92% for outpatients, 94% for inpatients and 90% for urgent and

emergency care. All services were similar to the England average, apart from inpatients and

urgent and emergency care at Gloucestershire Royal Hospital which were worse than the England

average. In September 2018 the maternity specific friends and family test stated that 93% of

patients would recommend the trust to friends and family.

Is this organisation well-led?

Leadership

To write this well-led report and rate the organisation we interviewed the members of the board,

both the executive and non-executive directors, the board of governors and a range of senior staff

across the trust. We met and spoke with over 250 members of trust staff to ask their views on the

leadership, performance and governance of the trust. We looked at a range of performance and

quality reports, audits and action plans, board meeting minutes, and papers to the board. We

reviewed investigations, incidents, complaints and feedback from patients, local people and

stakeholders.

The trust’s leadership team had the experience, capacity, capability and integrity to

manage a well-led organisation. There was a board of individuals with different and

complementary strengths and skills, providing collective leadership. The trust board members

were a group of individuals with a wide range of NHS and commercial experience, knowledge and

skills, and long service in senior management.

The executive team had an appropriate range of skills, knowledge and experience. In

interviews and focus groups they demonstrated professionalism, integrity, and were passionate

about and ambitious for the trust. There was evidence from our conversations with senior people,

including the non-executive directors (NEDs), of an environment of cohesive constructive

challenge among the leadership team and a close working relationship where leaders felt valued

and respected, and listened to. We found evidence across the entire range of interviews we

conducted of a joined up and inclusive board, with a well-articulated and shared vision of the

future.

Deborah Lee, the chief executive officer (CEO) understood and could articulate the unique

qualities of her team. The trust was emerging from a period of instability and significant

challenge over the last few years; the board had undergone considerable change having been

almost entirely refreshed since the appointment of the CEO in June 2016. Only the medical

director remained in post from before this time. When we met and spoke with her, the CEO was

able to clearly and insightfully articulate the qualities and skill sets of her team, and to highlight

areas of strength along with targeted areas for development. She was able to describe how and

why the individuals had been selected, and she spoke very highly of their complementary

qualities, with an awareness of, and plan to close any gaps and deficits within the team.


It was apparent to us that all appointments had been made in close alignment with the

trust’s priorities and were values-based appointments. The trust’s chair, Peter Lachecki, had

joined the trust in November 2016, from a strong leadership background, and along with the CEO,

had transformed the executive and non-executive board membership. Both were held in high

regard by the executive and non-executive members and the governors.

The non-executive director (NED) appointments had been drawn from a wide and relevant

range of expertise and experience and again had been carefully selected in alignment with

the trust’s priorities and values. There were five NEDs in post, having been appointed between

May 2016 and June 2018, with the majority having been appointed in the last 12 months.

Following a review of skills and experience among the NEDs, and on realising there were deficits

around clinical, estate/asset management, digital and integration experience, effort was put into

recruiting NEDs with this expertise. We found evidence of a good matrix of NED deployment which

had been carefully thought through; there was a NED from each sub-committee of the board on

each committee. From our conversations with them, we were assured of their significant skills and

experience. It was possible to see their influence as part of the overall effective leadership of the

trust. The board was described by the NEDs as supportive, open and transparent, and those we

spoke with described feeling valued and proud to be part of the team.

In Spring 2018, NHSI carried out a review of actions taken and were satisfied the trust had

taken appropriate steps to improve financial governance. Financial governance arrangements

were greatly improved from the position identified by the 2017 reviews and were now deemed to

be adequate. When Following external reviews of financial reporting at the trust in August 2016

and May 2017, material concerns were identified with the trust’s arrangements, leading to NHS

Improvement (NHSI) placing the trust into financial special measures in October 2016. The CEO

commenced in post in June 2016 and she was instrumental in identifying the underlying financial

deficit and had ascertained there was a lack of financial expertise on the board. Significant

progress had been made and the trust was lifted out of financial special measures in November

2018. NHSI confirmed for us that the trust board was fully established. NHSI judged the board as

having relevant financial expertise across the executive team (including non-executives).

The trust board had a sound understanding of and approach to the trust’s financial

position and areas of opportunity. The Director of Finance was appointed in June 2018, having

previously held the role of Director of Operational Finance at the Trust since May 2016. Two of the

recently appointed NEDs were qualified accountants. A review of board minutes suggested

appropriate time was spent covering finance and resourcing, and there was a separate finance

and digital committee to provide the more detailed review on behalf of the board.

The trust had created an associate NED role and was actively promoting this to British

Minority Ethnic (BME) underrepresented groups. Of the executive board members at the trust,

0.0% were British Minority Ethnic and 50.0% were female. Of the non-executive board members

0.0% were BME and 43.0% were female. The lack of diversity with the executive board was

recognised and highlighted to us by the chief executive officer and reflected in board papers

regarding recruitment.


Staff group BME % Female %

Executive directors 0.0% 50.0%

Non-executive directors 0.0% 43.0%

All board members 0.0% 46.0%

(Source: Routine Provider Information Request (RPIR) – Board Diversity tab)

The council of governors was an established group, and had a positive impact on the

way the trust communicated with the local community, although further work was required.

Governors have an important role to play in the governance of a foundation trust; they are the

direct representatives of local interests, and although they do not undertake operational

management of trusts, they challenge NEDs individually and collectively holding them to account

for the trust’s performance. It is also the governors’ responsibility to represent the interests of the

public and members in their constituencies, particularly in relation to the strategic direction of the

trust. There were 22 elected and appointed Governors on the Council.

The council of governors had sufficient time to interact with the board. The lead governor

met separately monthly with the CEO and chair and met with the director of corporate governance.

Pre-meetings were held ahead of the council of governors quarterly public meetings, which were

very well attended and useful to hone the issues for presentation at the main meetings; a trial had

commenced whereby a NED was invited to the last half an hour of the pre-meeting. The executive

and non-executive teams also attended the public meetings. There was some concern that too

much time was being spent at the formal meetings on presentations about performance, and that

was under discussion. The governors told us they would welcome more support in terms of

engagement with the membership and overall engagement with members, patients and public and

this was an area for improvement acknowledged by the board. A dedicated band 6 resource had

been provided earlier in 2018 to support the council of governors with committees, working groups

and membership.

When we met with the governors they told us the last two years had seen a period of

stability. Engagement and relationships with the board had improved significantly with the new

CEO and chair, and they felt there was now a real sense of openness and transparency. They

were able to articulate how they communicated with the board, and gave examples of where their

influence had an impact. The board had agreed for governors to attend the board committees as

observers to add their perspective to business, and this was a positive step.

There were opportunities and programmes running for development in senior leadership,

including opportunities for staff below team manager level. A wide range of leadership

development was on offer, along with networking opportunities for leaders and aspiring leaders at

all levels. We saw evidence of comprehensive induction programmes for directors, NEDs and

governors, and those we spoke to felt they had been adequately prepared and supported in their

roles. We saw evidence of a board development programme which aligned to strategic objectives,

and we heard about board coaching sessions that had taken place. The Trust allocated two half

days per year for governor development sessions to provide training on specific topics such as in

their statutory role of holding NEDs to account for the performance of the board. Additionally,


executive leadership spent time with a mentor quarterly to “get the board away from the business”

and focus on development.

A roadmap for embedding talent had been developed. This aimed “to identify and leverage the

full potential of every single member of our workforce to deliver our vision of ‘Best Care for

Everyone’.” A talent workstream was in place, overseen and monitored by the workforce

committee, which had clear goals and objectives aligned to the trust’s strategic direction. Central

to these were attracting, managing, developing and retaining talent. Recruitment processes had

also been overhauled to ensure a values-based methodology. The trust had introduced a new

accelerated development pool. An intranet site had been launched to support this, along with

management training and resources to ensure talent conversations formed part of the initial and

ongoing appraisal process. A talent review panel was in operation to select candidates put

forward, or self-referred, for entry to the accelerated development pool. Staff we spoke to during

the inspection told us about this, and how their appraisal and career conversations had been

transformed, although in some areas this was still embedding.

Succession planning was in place throughout the trust. For example, a Chief Nurse Junior

Fellowship programme had been implemented, targeting junior nurses for fast track development.

There were four junior nurses going through this programme; protected time was allocated for

them to undertake a quality improvement project sponsored by an executive and they were able to

access personalised coaching, leadership training and to shadow other senior professionals for

‘insight days’. On completion, they would be added to the accelerated development pool for 12

months. In addition, the trust was offering higher apprenticeships and university modules covering

leadership to interested staff. 11 trust staff had also applied for ‘The Stepping Up’ programme for

aspiring black, Asian and minority ethnic leaders.

The trust had signed up to leadership programmes and staff were able to access

standalone leadership workshops. The trust had launched a ‘100 leaders network’ in January

2017 to drive and empower senior leaders in the organisation. Due to the success of this the trust

had developed a similar network for band 6’s and 7’s in the organisation. Staff had representation

on the senior director’s forum, the extended leadership network and the One Gloucestershire

integrated care system (ICS) development programme amongst others. There was a leadership

and development and a coaching strategy in place.

The trust met its obligations to ensure directors were fit and proper persons. The trust had

robust and thorough processes for the recruitment and management of executives and non-

executives. The trust had a policy to ensure, to the best of its knowledge, that the directors met the

requirements to be fit and proper persons in accordance with the requirements placed on NHS

providers. Staff were responsible under their terms of employment to inform the trust immediately

if something should change the information given in their assurance report to the trust. We

checked personnel files for all executive and non-executive board members. There was a robust

policy which had been implemented effectively and was in accordance with regulation 5 of the

Health and Social Care Act 2008. All executive staff had a checklist which summarised the

process followed. The chief executive had a fit and proper persons check performed by an

external company.


There were processes which were consistent with trust policy. This included information on

recruitment, competency-based interviewing (including focus groups with staff), disclosure and

baring service checks, qualification checks, employment checks, and occupational health checks.

All personnel files had information regarding their most recent annual appraisal. This included 360-

degree feedback by gathering evidence from governors and other employees of the trust for

developmental purposes and analysing skills and behaviours. The appraisal process had recently

been refreshed and leaders told us this had transformed the quality of the discussions.

Leaders at all levels were visible and approachable for their patients and staff. There was a

programme of board visits to services and staff fed back that leaders were approachable. We saw

evidence of several initiatives to increase visibility and approachability of the leadership team. We

heard about learning from ‘back to the floor’ days, board led safety and engagement visits,

executive and divisional leadership walkabouts and monthly (filmed) ‘Involve’ sessions. However,

staff in outpatients at Gloucestershire Royal Hospital felt they were forgotten about and were not a

priority for senior staff visits.

Most staff we spoke to in focus groups knew who the executive team were and could

mostly name them. We spoke with over 250 staff from across the trust and from both sites, and it

was apparent to us staff felt visibility, approachability and engagement with the senior leadership

team had changed over the last 12 – 18 months for the better. Many staff told us they found the

new board approachable and felt they could contact them directly if needed. Some staff gave

examples of stopping the CEO in the corridor to talk to her, and staff were very positive about the

visibility of the director of nursing, who had used creative ways to connect with staff, for example,

setting up a ‘chocolate hotline’ for staff working on Christmas day. Social media was widely used,

and staff told us they valued this. The NHS staff survey does not specifically ask staff about the

visibility of senior management but does ask about communication between senior management

and staff. In the 2017 survey, two of the three indicators associated with management had

deteriorated slightly since 2016, and one was the same. All three indicators were below (worse

than) the national average for acute trusts. However, it was noted that these results reflected a

period of transition during the previous year, and the implementation of an almost entirely new

board.

The leadership team understood the challenges to quality and sustainability and they could

identify the actions needed to address them. Our interviews with the senior leadership team

brought out common themes around challenges to the organisation. None of the issues we raised

with the leadership team came as a surprise. These were reflected in documents we read,

including the board and sub-committee papers, the risk registers and articulated by many staff

throughout the trust. Safe and high-quality patient care was reflected within all the priorities for the

leadership and could be seen throughout trust documents.

Vision and strategy

The trust had a clear vision and set of values with quality and sustainability as the top

priorities. Leaders and staff we spoke with across the trust were able to talk to us about the vision

and values, and these were displayed on the website and around the hospital. The trust’s vision


was ‘Best Care for Everyone’. Their mission was ‘Improving health by putting patients at the centre

of excellent specialist health care.’ The goals were described in four core areas:

‘Our Patients: to improve year on year the experience of our patients’. ‘Our Staff: to develop further a highly skilled and motivated and engaged workforce which

continually strives to improve patient care and Trust performance’. ‘Our Services: to improve year on year the safety of our organisation for patients, visitors

and staff and the outcomes for our patients’. ‘Our Organisation: to ensure our organisation is stable and viable with the resources to

deliver its vision’.

After listening to patients and staff the trust had identified six core values, which were

described in the words of patients. Leaders and staff we spoke with across the trust were able

to describe how they were implementing these values in their work, and in developing services

further. These values were:

Listening - patients said: "Please acknowledge me, even if you can't help me right now. Show me that you know that I'm here."

Helping - patients said: "Please ask me if everything is alright and if it isn't, be willing to help me." Excelling - patients said: "Don't just do what you have to, take the next step and go the extra mile”.

Improving - patients said: "I expect you to know what you're doing and be good at it." Uniting - patients said: "Be proud of each other and the care you all provide." Caring - patients said: "Show me that you care about me as an individual. Talk to me, not

about me. Look at me when you talk to me."

There was a realistic strategy for achieving the priorities and delivering good quality

sustainable care. The trust had a strategic plan in place for 2014 – 2019 and was in the process

of undertaking a renewal of this for the period 2019 – 2024. The Trust’s management structure is

based around four clinical and two non-clinical divisions including the Trust’s wholly owned

subsidiary company: Gloucester Managed Services (GMS). There was a clear route map and

timeline for the renewed strategy, incorporating divisional plans as well as the multiple internal

drivers to shape the strategy.

The board had been involved in agreeing 20 strategic objectives that described what Best

Care for Everyone will look like in April 2019. The board held strategy and development

Sessions for individual strategies in the trust. This included the cancer strategy in November 2017;

the staff survey strategy in February 2018; the capital programme strategy in April 2018; and the

digital strategy in July 2018. These were still ongoing. The leadership understood and could

articulate the challenges to delivering the strategy and we saw evidence in the board papers of

regular discussions or risks to delivery, and quarterly reviews of progress against strategic

objectives, through the board assurance framework.

There was cooperative working with external partners to develop an integrated care system

in the county of Gloucestershire. The trust was involved in the design and implementation of a

county wide strategy in the context of the One Gloucestershire Sustainability and Transformation

Programme (STP) and the development of an Integrated Care System (ICS). The renewed

strategy was due to be submitted to the board in December 2018, and in place by April 2020. The


Trust worked closely with systems partners across ‘One Gloucestershire STP’ and had recently

been awarded ICS status with the CEO of the Trust being an active member of the STP board.

The leadership team regularly monitored and reviewed progress on delivering the strategy

and local plans. The board assurance framework identified strategic objectives and were

reviewed by the board quarterly. This included discussing risks affecting the strategic updates, and

performance against the operational plan. The operation plan was reviewed annually. Local plans

were reviewed as sub-committee level and reports were presented to the board on a regular basis.

Staff knew and understood the trust’s vision, values and strategy and how achievement of

these applied to the work of their team. Each division had been working to develop individual

service line plans for their service’s ‘journey to outstanding’. We saw evidence of a number of

these, including their strategic priorities. The trust’s quality improvement strategy in line with their

‘Journey to Outstanding,’ had been implemented from the bottom up, and was seen to be driving

new levels of staff engagement. Work was underway to reconfigure services, and this was running

ahead of the renewed strategy in part – this was to enable the trust to address the operational

challenges as soon as possible, given the impact on patients, staff and performance. However, the

trust told us there would be opportunities to align the thinking on service reconfiguration with the

emerging and final strategy to ensure they are coherent and aligned. Further work was therefore

required to ensure that staff, patients, carers and external partners had an opportunity to

contribute to discussions about the strategy, particularly where changes to services may be taking

place. The leadership team had highlighted this to us during the inspection. We saw evidence that

the vision and values were well advertised around the hospital and on the trust’s intranet, as well

as on the trust’s website.

The governors had been involved in the development of the trust’s clinical strategy, quality

priorities, complaints processes and the emergency care pathway. However, the three key

areas that had dominated time over the last 12 months were financial issues, the new computer

system and the establishment of a subsidiary company, Gloucester Managed Services (GMS).

There was evidence the governors provided challenge, and they told us they had felt listened to.

Culture

Staff felt respected, supported and valued and as a result felt positive and proud to work

for the organisation. Many of the board staff commented on a significantly improved culture

since the appointment of the chief executive and changes in the senior management team. One

described how the “cultural change was palpable”, another said “the difference between night and

day”, and a third said “the culture changed almost overnight”. The chairman of the trust reflected

“that it feels like a different world from the last inspection”. This was echoed in focus groups and

was a consistent message from staff we spoke with. One member of staff said, “we are in a period

of transition” and felt “there was better things to come after going through a low phase”. Another

said, “we have never had such an enthusiastic senior team”.

Staff in the IT team felt that culture had been greatly improved for them. With the migration to

an electronic patient record the team felt they were struggling with the challenges and the


workload. The introduction of a chief digital officer at executive level brought several teams

together under one manager and improved teamworking on IT systems and infrastructure.

Additionally, the IT team felt they had a voice at executive level and that their views and opinions

were heard and listened too. One member of staff described this as “collective and powerful”.

Response rates to the 2017 NHS staff survey were better than the average for trusts in

England. The survey was sent to all staff and had 3622 responses (47%) compared with an

England average of 44% and was comparative with the 2016 NHS staff survey. The trust had a

‘people and organisational development steering group’ who’s aim was to look at statistically

significant findings in the survey and identify and manage actions to improve these. There was

also a ‘staff experience improvement group’ which was chaired by the deputy director of people

and organisational development which provided a strategic view of the experiences of staff across

the trust and provided updates to the board with action plans to manage identified areas of

improvement.

Some of the executive team recognised that the pace of change could at times be difficult

for staff. Staff recognised the need for change and the senior leaders had been working with staff

to support change and apply any learning to future change initiatives. One member of the

executive team said that “we are on the cusp of going too fast and need to embed the change”.

We were given examples by the executive team where changes could have been embedded

better, such as reconfiguration changes in trauma and orthopaedics. However, they could give

examples of where they had learnt from this, for example with changes in surgery, and

demonstrated a commitment to ensure the lessons were carried forward. The trust was developing

a ‘management of change’ toolkit informed by the learning.

Cooperation with trade unions needed to improve. We heard conflicting views about how well

the trust cooperated with trade unions and found there to be some tensions. We spoke with trade

union representatives from the major unions as a focus group and many felt they were

undervalued by the executive team. At recent meetings the chief executive and the director of

people had been unable to attend, although they had attempted to reschedule one of the meetings

and had sent a deputy for another. Some union representatives found the attitude of the chief

executive aggressive in meetings and felt other executives were not engaged in involving the trade

unions with key meetings. One example given was a safety committee which the staff side health

and safety representative was not invited to. However, the trust told us the terms of reference for

the safety committee included trade union representatives and they regularly attend.

Trade union members sat on various groups across the organisation. The trust told us in

addition, the trade union representatives sat on the following groups: people and organisational

development delivery group, recruitment and retention working group, policy and governance

group, equality and diversity steering group, staff experience and improvement group, freedom to

speak up group, health and wellbeing group and are members of all job evaluation and

consistency panel processes.

Some representatives described consultations as “done deals” and not a platform for

change which was frustrating for the staff side. However, we saw forums for union

consultation included joint staff side committee, the local negotiating committee and the medical

staffing committee. Trade union representatives had also been part of the people engagement

group and had sat on the executive programme board which developed and executed the solution


for the implementation of the Gloucestershire Managed Service (GMS), which despite the

considerable changes it brought about, had been very successful. The CEO acknowledged more

work was needed to improve relations with the unions when we spoke with her.

There was an emphasis in the trust on the safety and wellbeing of staff. The trust had a

health and wellbeing strategy which was developed by a staff health and wellbeing group with

input from union representatives. This strategy built on five key strategy’s set out in national

papers and identified objectives including the development of a wellbeing action plan, de-

stigmatising issues surrounding mental health, developing a sense of community in the trust, using

data effectively, and giving staff access to care and support where needed.

There were numerous benefits available to provide opportunities for staff to maintain and

improve their health. There was self-referral access to physiotherapy which provided staff instant

access to an urgent appointment. There was also access to subsidised swimming and discount

gym membership, smoking cessation support, occupational health support, staff support, childcare

facilities and family friendly working, cycle to work schemes and a staff choir.

However, some found it difficult to access services. The trust employed health and wellbeing

coordinators. Staff in focus groups felt that the waiting list for these services were too long. For

example, some staff said that the waiting list to access these services was between eight and ten

weeks. One member of staff said that “this wait was too long when I needed it and resulted in me

going off sick”. Staff who had accessed the service found it positive and worth the wait. In medical

appraisals mental health wellbeing assessment tools were used to identify concerns.

Junior doctors were supported by a senior doctor who was the guardian of safe working

hours. The trust had appointed a Guardian of Safe Working Hours (GSWH) to provide assurance

to the trust board, the General Medical Council and Health Education England (and to the doctors

themselves) that doctors in training were safely rostered. Furthermore, their working hours should

be reported as compliant with their terms and conditions of service. The guardian was required to

raise concerns to the trust board and potentially to external bodies if this was not the case. We

met with the current guardian who, as required, was a senior doctor within the trust, and

independent from the management structure. They had been given protected time in their working

hours to hold this post. The medical director was the executive sponsor. The GSWH described

being supported and included by the board and was able to give examples of constructive

challenge that had led to further exploration, for example, the correlation between safe working

hours and incidents. We found evidence of the GSWH taking a proactive role.

The trust had implemented an exception reporting process for working hours or

educational opportunities that varied from those in work schedules. Doctors in training could

raise an exception report whenever working hours breached those set out in their work schedule.

Exception reports were reviewed and addressed by the educational supervisor or nominated

deputy. If appropriate, time off in lieu or payment for extra hours worked was agreed and in certain

circumstances, a fine could be levied for exceeding safe working limit. These reports were

overseen by the GSWH and compliance reported to the board quarterly. A quarterly report was

submitted to the board and we could see that where issues had been highlighted, targeted action


had been taken. For example, in areas where reporting was high, the GSWH was working with

those teams and departments to understand and improve working conditions.

The GSWH had identified a significant number of reports were not being processed by

supervisors and were just being paid and closed. However, an agreed template had been

introduced along with a new reporting system, to identify which supervisor would process reports,

and a weekly reminder system was put in place; a deadline was set, after which the trainee would

be paid, and a notification sent to the supervisor and the head of department. This had helped to

give the trainees confidence that the system was functioning. Following the introduction of this

system, the GWSH could demonstrate a definite improvement in response rates. A quarterly junior

doctor forum had been set up with meetings held alternately at Cheltenham General Hospital and

Gloucestershire Royal Hospital; attendance was good, junior doctors were engaged and raising

concerns.

Staff felt able to raise concerns. Staff in focus groups felt that because of increased

transparency at board level directors were more approachable. Staff commented that the chief

executive officer and the director of nursing were most visible and felt comfortable talking to them

and raising concerns. Some staff could give examples of where they had raised concerns with the

chief executive officer and had them handled in a responsive and compassionate way.

Students felt they were supported and were able to speak up. As part of the focus groups we

spoke to nursing, allied healthcare professional, and medical students. They described positive

experiences and said that the teams were good compared to other placements they had been on.

They said there was a culture of support and training in the hospitals. Where there had been

concerns, they were supported by their supervisors to speak up.

The trust and its staff recognised the need to be able to speak-up. The need to provide better

support for NHS workers to raise concerns was highlighted in the Francis Freedom to Speak Up

Review, published in February 2015. The review was set up in response to evidence that NHS

organisations did not appropriately react to the concerns raised by staff, including the

maltreatment of those speaking up. The review set out 20 principles of good practice in supporting

speaking up and how such support should be provided. The principles addressed fostering a

culture of safety and learning in which NHS staff could raise concerns, appropriate policies and

procedures for handling them, measures to support good practice and for vulnerable staff groups,

including bank, agency and BME staff.

The trust had appointed a Freedom to Speak Up Guardian and provided them with

sufficient resources and support to help staff to raise concerns. A freedom to speak up

guardian had been appointed in April 2017 and had one day per week allocated to speak up work,

alongside their other role. There was a non-executive sponsor who was very supportive, and

access to the board was good. A speak up steering committee had been set up, and was attended

by the NED, the director of safety and the director of people. The speak up strategy was being

developed, and the trust’s raising concerns policy was being refreshed, with a view to adopting the

national policy on freedom to speak up (whistleblowing) that had been developed by NHS

Improvement.


Staff knew how to use the whistle-blowing process and about the role of the Speak Up

Guardian. We asked questions regarding he freedom to speak up guardianship in focus groups

and found that almost all knew who they were and that they were approachable. Staff found

information shared in trust messages during a ‘freedom to speak up month’ embedded learning

and made them more confident of the process. However, junior doctors consistently were not

aware of who the freedom to speak up guardian was, or how to access them. Although,

commented they would contact the guardian of safe working hours if they needed to raise any

concerns.

The trust applied Duty of Candour appropriately. The trust had appointed the director of safety

as the duty of candour lead who had oversight of the application of duty of candour for complaints,

incidents and deaths. We reviewed a selection of incidents and complaints and found that the duty

of candour had been applied appropriately and sensitively. Where duty of candour was triggered,

a family liaison officer was appointed as a key point of reference to support the family in navigating

the processes and this was exemplary practice not seen in most other organisations.

The trust encouraged openness and honesty at all levels of the organisation in response to

incidents. The duty of candour is a regulatory duty that relates to openness and transparency and

requires providers of health and social care services to notify patients (and other relevant persons)

of certain ‘notifiable safety incidents’ and provide reasonable support to that person. All staff were

trained at induction to understand and recognise the duty of candour. All staff we asked in focus

groups felt that the duty of candour, being open, and transparency fully embedded in the trusts

culture. One member of staff described the duty of candour as “something we just do, we don’t

even have to think about it anymore”.

Staff Diversity

The trust provided the following breakdowns of medical, nursing and midwifery staff by Ethnic

group.

Ethnic group

Medical

and dental

staff

Nursing and

midwifery

staff

(%) (%)

White 71.9 77.5

Mixed 2.4 0.8

Asian 14.1 8.5

Black 1.7 2.7

Chinese 1.2 0.2

Other 2.5 7.5

Unknown / Not Stated 6.2 2.9

(Source: Routine Provider Information Request (RPIR) – Diversity tab)


Equality and diversity were promoted within and beyond the organisation. The trust

published its latest equality, diversity and inclusion report which was published in February 2018.

The data relates to 2016/17 and the 2017/2018 report was due to be published following the

inspection in December 2018. Additionally, to this the trust produced an ‘equality and opportunity

action plan’ which was published in September 2018 with the latest action plan for 2019/20 due to

be published in August 2019.

The trust complied with NHS England’s requirements to complete and publish a Workforce

Race Equality Standard (WRES) survey. This published key indicators and described the experience

of black and minority ethnic staff. This linked with the equality, diversity and inclusion report and action

plans. The trust had set up a diversity network and held listening events for staff. We saw these

meetings were being held approximately every two months, along with other events to coincide with

campaigns or festivals, such as Mental Health Awareness, Pride month, International Women’s Day

and Black History month. The trust had also embedded equality and diversity indicators into all

leadership development opportunities.

Although equality and diversity were promoted, the NHS staff survey 2016 highlighted there

were some areas of discrimination within the trust. The scores presented below are questions

relating to bullying and harassment split between white, and black and minority ethnic (BME) staff,

as required for the workforce race equality standard. The trust had recognised this and had

identified that most cases were from members of the public to staff. Mediators had been

introduced to manage new cases of harassment.

Notes:

These scores are un-weighted, or not adjusted. For questions 17b, the percentage featured is that of ‘Yes’ responses to the question.

(Source: NHS Staff Survey 2017)


Of BME staff working at the trust, 32% had experienced harassment, bullying or abuse from

patients, relatives or the public in the last 12 months. This is worse compared to 29% of white

staff and is 4% worse than the average for acute trusts. This was also worse compared with the

results in the 2015 staff survey.

Of BME staff working at the trust, 28% had experienced harassment, bullying or abuse from

staff in the last 12 months. This was slightly worse than the percentage of white staff but was

comparable to the average for acute trusts. This was also slightly worse, by 2%, than the results in

the 2015 staff survey.

Of BME staff working at the trust, 16% had personally experienced discrimination at work

from a manager, team leader or other colleague. This was statistically significant and double

that of white staff working at the trust but was comparable to the average for acute trusts.

Of BME staff working at the trust, 79% believed that the organisation provided equal

opportunities for career progression and promotion. This was statistically significant and was

slightly worse than the percentage of white staff working at the trust but was better than the

average for acute trusts.

The trust was preparing for the forthcoming Workforce Disability Equality Standard. This is

a set of specific measures to enable NHS organisations to compare the experiences of disabled

and non-disabled staff. Actions included reviewing and updated processes in relation to

reasonable workplace adjustments to ensure a consistent and transparent approach to making

workplace adjustments.

There were negligible differences in pay between male and female workers and that

differences in pay were predominately due to length of service rather than gender. The trust

published on its website information as part of the requirements to participate in national gender

pay gap reporting. The report identified that 82% of staff at the trust were ‘non-medical’ and were

remunerated from agenda for change therefore was a negligible difference in pay. Analysis of the

medical workforce showed there was a gender pay gap within the senior medical workforce.

However, found that it was related to length of service determined by national terms and

conditions.

Staff appraisal rates, turnover rates and sickness rates

Not all staff had the opportunity to discuss their learning and career development needs at

appraisal. In September 2018 the percentage completion rate for appraisals was 80%. Because

of this the completion rate for appraisals had been added to the ‘exception report’ in the quality

and performance report for additional scrutiny. The report highlights that compliance had

increased between August and September with additional reporting and focused targeting of poor

compliance areas being actioned. These actions had an executive level owner to ensure board

oversight of the risks. In July 2018 the trust had launched a new appraisal process with the new


title ‘development conversation’. A key aim of the new process was to focus on learning and

development needs. Some staff we spoke with had been through this process and were positive

about it.

In the 2017 NHS Staff Survey 87% of staff said that they had an appraisal in the last 12

months. This was slightly better than other acute trusts. The quality of appraisals was 2.95 out of

a maximum of 5. This was slightly worse than the 2016 NHS Staff Survey score and was below

the average of 3.11 for acute trusts.

The turnover of staff had been stable between September 2017 and September 2018 but

had consistently been worse than the trust target of less than 11%. Whilst the trust had not

met the 11% target in all staff groups, it was one of the highest performing trusts in the region.

Between September 2017 and September 2018, the average turnover rate was 12.3%. This was

only slightly worse than NHS turnover rates published by NHS Digital for the previous 12 months.

However, senior managers shared that the turnover for healthcare assistants was higher,

averaging at 20%. The trust recognised this and had brought in new leadership to change how

interviews were conducted. There was evidence to show the rates had improved over the last 12

months, and the trust had a good staff retention rate of 86.7%, making it the second highest (best)

quartile nationally. Additionally, vacancy control processes were in place and reviewed two-three

times per week, and recruitment trajectories had been implemented to manage the replacement of

staff who leave.

Sickness and absence figures were not outliers. The trust’s sickness absence levels from June

2017 to April 2018 were slightly better than the England average. Low levels of sickness absence

can be an indicator of a good culture in an organisation and good management of pressure at

work. However, in the 2017 NHS staff survey scores had deteriorated by 5% (from 33% to 38%)

when staff were asked if they had ‘felt unwell due to work related stress in the last 12 months’, had

deteriorated by 3% (from 52% to 55%) when asked if they had ‘attended work in the last three

months despite feeling unwell because they felt pressure from their manager, colleagues or

themselves’.

General Medical Council – National Training Scheme Survey

In the 2018 General Medical Council (GMC) Survey the trust performed the same as

expected for all 18 indicators. The trust was performing better than in the 2017 survey. Every

year the GMC survey all doctors in training and trainers for their views. This is to ensure that

doctors in training receive high quality training in a safe and effective clinical environment, and that

trainers are supported in their role.

(Source: General Medical Council National Training Scheme Survey)

Governance

The trust had effective structures, systems and processes in place to support the delivery

of its strategy including sub-board committees, divisional committees, team meetings and


senior managers. Leaders regularly reviewed these structures. The trust wide governance

architecture and quality structures had recently been refreshed and were becoming established

and we found there was a good emphasis on challenge and assurance, as well as support. The

Quality Framework is the key document describing the quality governance arrangements within

the trust. The framework describes quality under the key lines of enquiry (KLOEs), namely, well

led, safe, effective, responsive and caring. A reporting framework and committee structure

reaching into the organisation provided assurance on a continuous basis and identified good

practice and areas of concern. Key quality risks were monitored through the risk management

process on the trust risk register and the Board Assurance Framework.

The senior leaders were able to articulate what was working well, and which areas needing

further work. The terms of reference for the various board sub-committees had been revised and

were to be presented to the board for approval in November 2018. For example, further work was

underway to review reporting lines and delivery group terms of reference, and to ensure mapping

and communicating decision making routes were embedded in the new structures. We reviewed

papers for board meetings and other committees and found these to be of a good standard,

containing appropriate information and evidence of challenge. All committee assurance reports

were submitted to the public board. An established programme of board visits to clinical areas

supported triangulation of assurance presented in assurance reports.

Non-executive and executive directors were clear about their areas of responsibility. We

sampled and reviewed some of the executive and NED portfolios and found these clearly set out

areas of responsibility and accountability; we also found that these had been well considered and

tailored to individual skill sets to make the best use of areas of expertise. NEDs were involved in

major projects for example the establishment of a subsidiary company, the development of the

governance arrangements for the integrated care system and the capital programme. Staff at all

levels of the organisation understood their roles and responsibilities and what to escalate to a

more senior person.

A clear framework set out the structure of ward/service team, division and senior trust

meetings. Managers used meetings to share essential information such as learning from

incidents and complaints and to act as needed. There was a traditional divisional structure with

four clinical divisions each with a triumvirate model, and a corporate services division. This

represented a clear clinical leadership structure with a single responsible individual, known as

chief of service with a strong clinical background at the head of each division who worked

alongside managerial, other clinical and operational colleagues. Governance meetings across the

trust from ward level to board contained standing agenda items for risk, emerging issues and

incidents however, further work was required in some clinical areas, for example in surgery where

there was new leadership, to embed the management of risk, which is discussed below. We found

in general there was a good read up and down in relation to learning from incidents and

complaints, and these were fed into quality improvement programmes; we saw several examples

of issues being escalated, and quality improvement taking place as a result.

A partnership arrangement was in place for the provision of psychiatric liaison services

with appropriate governance arrangements. The service had a mental health strategy

appropriate for patients with mental illness that was approved by the Board and reviewed annually.


A clinical lead who was a board member was responsible for the mental health strategy and the

development of clear, measurable health outcomes. The director of nursing was the board lead for

mental health and there was a NED lead for mental health as well as safeguarding. Governors

were involved in the mental health strategy and they also had a nominated mental health lead.

There was a service level agreement (SLA) with another local NHS trust to provide mental

health liaison. This included adult mental health provision to the emergency department twenty-

four hours a day; dementia and alcohol liaison Monday to Friday nine to five. It did not include

learning disability liaison who are employed directly. A new business case was being considered

which included bringing the liaison services in house, and ensuring all age inpatient liaison,

including children. Inpatient liaison is acknowledged as enhancing and bringing together mental

health services such as dementia, delirium and learning disabilities under one strategy.

Mental health act administration was also subject to the SLA above. However, we saw a lack

of understanding in respect of the application of the mental health act (1983). A patient had been

illegally detained on a section 5(2) due to incorrect paperwork having been completed. Following a

detention on a section 2 a patient did not have it recorded whether they had received their rights in

accordance with the act. There was a lack of oversight and scrutiny from the mental health act

administrators provided via a service level agreement. A different patient had been placed on

section 17 leave from a mental health unit to the ward. However, no paperwork had been sent with

the person and the staff had no understanding of the parameters of the leave. We brought this to

the attention of the trust and measures were put in place to conduct an urgent review of the

processes.

The Emergency department (ED) department had access to 24/7 mental health liaison

support if they were concerned about risks associated with a patient’s mental health. Other

wards felt that the psychiatric liaison provided a good service, however due to being ED focussed

it was not as responsive as they would like. Outside of ED the input tended to be provided by the

liaison consultant and other medical staff. The trust had a health psychology department which

provided focussed intervention and staff told us they receive a very good service from this team.

There was poor communication at times between the liaison team and the emergency

department that resulted in a potentially serious incident that was averted due to the

actions of our inspection team. Handovers by the liaison team to emergency department staff

were not passed on to nurses in charge of the unit and records were not checked to understand

the level of risk posed. This meant that patients were not always supervised and were in an area

that was not fit for purpose due to bathrooms with multiple ligature points and unsupervised

access to the children’s waiting area.

We found that the provision of mandatory training for clinical staff on recognition and first

response to patients who have mental health needs, learning, disabilities autism and

dementia was in place. This primarily took the form of eLearning modules, the update of which

was good. However, staff told us that they felt the modules did not prepare them for working with

people with enhanced needs. Staff told us that the provision of face to face training was not

consistent. On some wards staff told us that they had face to face training, the subject areas


included the management of violence and aggression and how to apply safe holds to manage

aggressive patients. Staff on the older person’s wards told about the dementia liaison providing

training and other wards referenced the nurses providing training. None of the staff we spoke with

felt that they had received adequate training regarding autistic spectrum conditions. The trust had

commenced a programme of additional training in enhanced care (formerly specialing) for health

care assistants and was looking into the possibility of actively recruiting mental health nurses. The

trust acknowledged the challenges with caring people who are IV drug users however the

relationship with the relevant local providers of these services was positive.

Psychosocial assessments and risk assessments for patients thought to be at risk of self-

harm / suicide were carried out by the medical staff prior to a referral to the liaison

services. The Nurses interviewed had a limited understanding of how to assess somebody who

was at risk of suicide or self-harm. Staff demonstrated an awareness of the risks associated with

suicidal people and told us that they nurse people in beds that are easily observable and would

never place somebody in a side room.

Staff demonstrated a limited understanding of the Mental Capacity Act 2005. We observed

capacity assessments that were not decision specific. Capacity assessments were being carried

out by junior doctors who may have met somebody for the first time as opposed to Nurses who

may know the person better. The mental capacity act states that the best person to carry out an

assessment is the person who knows the individual best. Deprivation of liberty (DOLs) applications

did not adequately describe the treatment proposed or the restrictions to be placed upon

somebody. The trust acknowledged further work was required in this area, and it had recently

produced ‘simple guides’ on a number of topics, including the mental capacity act and deprivation

of liberty safeguards.

Board Assurance Framework

There was a well-established and understood board assurance framework (BAF) which set

out the trust’s strategic objectives, risks, controls and assurances on those controls. The

BAF complemented the trust’s risk management arrangements and provided an overview of the

organisation. Risks to the Trust’s strategic objectives were captured in the BAF and risks of an

operational nature were captured through divisional and departmental risk registers. The major

risks facing the organisation were those from operational pressures driven by demand exceeding

capacity, risks to patient experience and potentially outcomes associated with significant backlogs

of patients awaiting routine outpatient or inpatient care, and risks associated with delivery of the

Trust’s financial plan. We saw evidence of the BAF being used to direct board focus on key risks,

and to monitor controls and assurances. The BAF had been refreshed in early 2018 and was kept

under continual review. Quarterly reviews and updates were owned by the executives and

submitted to all board committees apart from remuneration. The BAF was reviewed and reported

on by the Audit and Assurance Committee, with the report submitted to the board. This set out

progress against strategic objectives along with any issues around achievability. The trust had

identified the BAF was very ‘busy’ in presentation and work was planned to improve this, along

with better analysis of issues in the summary narrative. Plans included using the BAF to

systematically set the board agenda, and to roll the BAF out to divisions.


The trust provided their Board Assurance Framework, which details 20 strategic objectives

within each and accompanying risks. A summary of these is below:

1. Be rated good overall by the CQC 2. Be rated outstanding in the domain of ‘Caring’ by the CQC 3. Meet all national access standards 4. Have a hospital standardised mortality ratio of below 100 5. Have more than 35% of our patients sending us a family friendly test response, and of

those 93% would recommend us to their family and friends 6. Have improved the experience in our outpatient departments, reducing complaints to less

than 30 per month 7. Have an Engagement Score in the Staff Survey of at least 3.9 8. Have a ‘Staff Turnover Rate’ of Less Than 11% 9. Have a Minimum of 65% of ‘Our Staff Recommending Us as a Place to Work’ through the

Staff Survey 10. Have trained a further 900 bronze, 70 silver and 45 gold quality improvement coaches 11. Be recognised as taking positive action on health and wellbeing, by 95% of our staff

(responding definitely or to some extent in staff survey) 12. Have implemented a model for urgent care that ensures people are treated in centres with

the very best expertise and facilities to maximise their chances of survival and recovery 13. Have systems in place to allow clinicians to request and review tests and prescribe

electronically 14. Rolled out Getting it Right First Time Standards across the target specialities and be fully

compliant in at least two clinical services 15. Have staff in all clinical areas trained to support patients to make healthy choices 16. Be in financial balance 17. Be among the top 25% of trusts for efficiency 18. Have worked with partners in the Sustainability and Transformation Partnership to create

integrated teams for respiratory, musculoskeletal conditions and leg ulcers. 19. Be no longer subject to regulatory action 20. Be in segment 2 (targeted support) of the NHSI Single Oversight Framework

(Source: Trust Board Assurance Framework – May 2018)

Management of risk, issues and performance

The trust had systems in place for the management of risk. The governance team regularly

reviewed the systems. There was a risk management strategy in place. The management of the

risk register was through the Trust Leadership Team (TLT), which met each month. The function

of this group was to validate new significant risks and remove mitigated risks from the register.

This process was replicated at governance meetings throughout the trust at departmental and

divisional level, to ensure that current risks and their controls / actions were on risk registers and

managed dynamically as the risk environment changed. A risk management group scrutinised the

risk management processes and reporting mechanisms, providing system assurance and holding

divisions and directors to account for the devolved management function.


An internal audit of risk management had been commissioned and was undertaken by an

external risk management company in December 2017. This concluded overall that the trust

had worked hard over the last two years to develop a strong culture of risk management, and

recognised the progress made, particularly in relation to the value added by the formation of a risk

management group. Two low level risks were highlighted around the articulated purpose of the

risk management group and the streamlining of their operations, and one advisory risk which was

to ensure a focus on the weaker divisions in terms of how they understand and manage their risk.

In April 2018, the risk management group had developed a risk management road map for

2018/19. This included information gleaned from recent reviews regarding gaps in the systems

and processes, aims and objectives for improvement going forward. There was a commitment to

ensure that risk management was aligned and integrated with strategic, business, financial and

performance objectives. The trust had identified a number of weaknesses which we also found on

inspection, for example, a disconnect in some areas with reporting and escalating risks. The lack

of awareness and understanding of some staff around the risk management processes had been

added to the risk register and measures had been put in place. Among the first priorities set out in

this document was the need to focus on the management of risk at divisional level and work was

underway to enable divisions to take better control and ownership of the risk functions. There was

a measurable target for this which was being kept under review. All key risks fed to the BAF, and

this was also being developed, along with more focused committee level risk reports with the aim

of offering insight, but also foresight.

There were systems and processes in place to manage incidents and to disseminate

learning. The trust had a strong culture of reporting and learning from incidents. Staff of all levels

were encouraged to report incidents and to seek feedback from their managers. Incidents reported

via the electronic database was overseen by the risk management group and any emerging trends

or themes were identified and investigated appropriately and reported via the group’s agreed

reporting lines. Serious Untoward Incidents (SUIs) were identified in a report and a verbal briefing

was provided to the quality and performance committee on a monthly basis. A summary of current

SUIs was reported to the trust board (bi-monthly). The purpose of the report was to provide

assurance that SUI investigations were carried out in a timely way and investigations and their

action plans were closed. The operational committee responsible for SUIs was the Safety and

experience review group which was chaired by the director of safety and had the executive

directors of Nursing and medicine as well as a clinical commissioning group representative in its

membership. This committee monitored progress of the investigations and any high-level trends

recommending any further investigation.

Serious incidents were managed well. We reviewed a sample of serious incidents during the

inspection and found these to have been managed appropriately, with appropriate investigations

having taken place; the quality of the root cause analysis reports was of a high standard, and we

were impressed by the degree of attention given to ensuring those affected were supported,

including staff, but particularly through the use of family liaison officers to support the patients

and/or their relatives during investigations.

Senior management committees and the board reviewed performance reports. Leaders

regularly reviewed and improved the processes to manage current and future performance and


risk. The Trust operates with the BAF to ensure the monitoring of strategic and operational

programmes of work. Effective reporting and assurance flows to the trust board, including a

monthly quality and performance report, supported by review at the quality and performance

committee. This report spans all aspects of the Strategic Oversight Framework and the CQC

domains, covering key quality, performance and financial metrics. Each division had a quarterly

divisional executive review to keep performance on track, and a set of early warning indicators had

been identified. An internal survey had been conducted, where the trust identified that although

risk management processes and terminology were well understood among senior leaders, this

was not so for all staff, and in particular for bands through 1 – 6, where understanding was poor.

As a result, ward level risk processes were reviewed, simple guides on risk were produced and

disseminated, along with the introduction of practical language that staff could readily relate to.

Risk eLearning had been introduced and risk management responsibilities were built into personal

objectives.

The trust board had sight of the most significant risks and mitigating actions were clear.

The majority of issues we found during this inspection had already been identified by the trust and

we were able to track through a number of these to tangible actions, with owners identified and

measurable, time limited expected outcomes. The items recorded on the risk register aligned with

what leaders told us were areas of concern, and in the majority of cases reflected what staff told

us was on their ‘worry list’. There was a sense from leaders and other staff we spoke to that

significant progress had been made in the identification and management of risk, and although

there was more work to do as highlighted in the core service reports, there was a clear

commitment to improve weak areas and keep these under a proactive review process.

Leaders were satisfied that clinical and internal audits were sufficient to provide assurance.

Teams acted on results where needed. There was an internal and clinical audit programme which

was monitored at divisional and corporate level. We saw evidence of audits having been

conducted and used to make improvements, and these were well aligned with the quality

improvement agenda. For example, in order to close the gap in ward to board assurance, the trust

had embarked on a nursing assessment and accreditation system (NAAS). This had been rolled

out and at the time of our inspection 39 clinical areas had self-assessed against the set quality and

performance indicators and approximately 26 areas had been NAAS team inspected. This NAAS

had been viewed as a really positive step and staff we spoke to had welcomed it. Ensuing

improvement programmes were owned by the relevant teams, and they were monitored and

followed up. This programme linked with the quality improvement programmes. The Trust had

made progress in improving and strengthening its internal control environment during 2017/18.

The issues noted in the course of 2017/18 internal audit reviews were fewer in number and of

lesser severity than in the previous year.

Trust corporate risk register

The trust provided a document detailing their ten highest profile risks. Each of these have a

current risk score of 12 or higher.


ID Description

Risk score (current)

F2335 The risk of excessively high agency spends in

both clinical and non-clinical professions due to

high vacancy levels.

20

C1748COO The risk of statutory intervention for failing

national access standards in relation to cancer.

16

S2275 The risk to workforce of an on-going lack of staff

able to deliver the emergency general surgery

rota due to reducing staffing numbers.

16

C2667NIC The risk of regulatory intervention as a result of

exceeding the avoidable annual Clostridium

difficile target.

16

C1609N Risk of poor continuity of care and overall reduced

care quality arising from high use of agency staff

in some service areas.

12

C1798COO The risk of delayed treatment and diagnosis due

to delays in follow up care in a number of

specialties including neurology, cardiology,

rheumatology, ophthalmology, general surgery,

urology, vascular, T&O and ENT.

12

C2669N Risk of reduced safety due to inpatient falls 12

S2595Th The risk of harm to patients due to correct and

sterile equipment not being available from CSSD

12

C2628COO The risk of non-delivery of appointments within 18

weeks within the NHS Constitutional standards

for treatment times.

The risk on non-reporting of RTT (incomplete)

standards.

12

C1945NTVN The risk of moderate to severe harm due to

insufficient pressure ulcer prevention controls

12

(Source: Trust Corporate Risk Register July 2018)

Staff in some focus groups felt that risks were not always escalated properly and that when

they raised concerns no or limited action was taken. We were given an example in cardiology

where a backlog of letters increased with no changes put in place to increase typing capacity

despite escalation. This was only acted upon when a significant backlog had accumulated.


There were plans in place for emergencies and other unexpected or expected events. For

example, adverse weather, a flu outbreak or a disruption to business continuity. Business

continuity plans, dealing with emergency preparedness and civil contingency requirements, were

in place across the trust and the chief operating officer was responsible for oversight. The trust

had been subjected to review of its emergency preparedness during 2016/17 and no serious

concerns were highlighted.

Winter Plan

There were plans in place for unexpected events over the winter period. This was

documented in the trusts winter plan. The plan clearly set out the organisations arrangements over

the winter period and was signed off by the executive team in November. It addressed actions

required by NHS England and identified lessons learnt from the winter period of 2017/2018. The

winter plan formed part of the system wide response to the winter period and was developed in

conjunction with partners such as NHS Improvement, the local Clinical Commissioning Group, the

local community and community mental health trusts.

Multiple projects were ongoing or completed at the time of the inspection to improve flow

through the hospital during the winter period. This included the movement and re-purposing of

wards over the winter period to improve capacity within the hospital and creating standard

operating procedures to ensure that areas, such as the day case surgical unit were not used for

escalation. We were given examples of where reconfiguration had improved capacity within the

hospitals. For example, the move of the gastroenterological ward meant that there was more

capacity for elective surgery, and meant it was easier to manage outliers within the hospital.

Additionally, the reconfiguration of some acute wards meant that there were facilities available for

a frailty service and 12 additional ambulatory care bays.

Senior management committees and the board reviewed the progress of the winter plan.

The chief operating officer had executive oversight of the winter plan and met with divisions to

discuss the winter plan every two weeks. The chief operating officer was the chair of the systems

wok on winter pressures and could describe how the trust had developed the winter plan and how

they had worked with stakeholders and partners to develop the plan and could describe how the

plan fit into the wider system work. This work included how organisations were working together to

predict when there would be surges in acute pressure. An example was given around receiving

information from GP services and community nurses to predict several days in advance when

there would be a higher than expected admission rate.

The trust executive team, the operational management team and external partners had

confidence in the plan. To build confidence in the winter plan, the trust commenced ‘stress

testing’ in October 2018 to ensure they were fully prepared and were assured that internal process

and escalation were effective. When speaking to Gloucestershire Clinical Commissioning Group, it

was commented that the plan was effective and were confident it was realistic and achievable. We

spoke with the chief operating officer and senior operation staff and felt that relationships with

external partners had improved and there had been an improved, multi-agency approach to the

winter plan this year. Examples were given about how they had worked better with the local


community trusts and with the local ambulance services to improve patient flow throughout the

healthcare system.

Finances Overview

Historical data Projections

Financial metrics Previous Financial

Year (2016/17)

Last Financial Year

(2017/18)

This Financial Year

(2018/19)

Income £506.2m £498.4m £523.3m

Surplus (deficit) (£18.0m) (£31.6m) (£17.9m)

Full Costs £524.2m £530.0m £531.2m

Budget (or budget

deficit) (£18.2m) (14.6m) (£17.9m)

(Source: Routine Provider Information Request (RPIR) – Finances Overview tab)

NHS Improvement had reviewed financial governance and they told us:

As at Month 6, the Trust reported to its Board an operational deficit of £16.7m. This is a

favourable variance to budget and NHS Improvement Plan of £0.2m. The most likely forecast

outturn deficit for the Trust was reported to be £22.7m which is an adverse variance of £3.8m

against the Control Total deficit of £18.8m (including Provider Sustainability Funding). This

reflects risks materialising including clawback of Agenda for Change funding for the Trust’s wholly

owned subsidiary.

Divisional managers and operational staff were understood the trusts cost improvement

plans and the reasons behind them. Where cost improvements were taking place there were

arrangements to consider the impact on patient care. Managers monitored changes for potential

impact on quality and sustainability. Staff could provide examples where cost improvement

projects had happened and could show how patient care had not deteriorated as a result.

However, there was more of a focus on quality improvement and making financial savings through

better care. One general manager said, “best care provides best finance”. Additionally, in focus

groups staff commented that the word ‘finance’ was not allowed to be part of any quality

improvement project as quality came first.

Information management

The board received holistic information on service quality and sustainability. The board was

updated with the trust’s performance at each board meeting through the presentation of the quality

and performance report. The report looked at performance of quality and safety throughout various


measurables throughout the core services. A summary page identified key themes and the

stability of the data provided. An executive summary identifies strengths and weaknesses

throughout the trust. The detail of the report drew attention through a RAG (red, amber, green)

rating system. This immediately highlighted which areas were low, medium or high risk. This was

pulled together into a summary scorecard which provided overall RAG ratings for quality,

operational performance, finance and leadership and development. This comprehensive report

focused on significant indicators such as complaints, waiting times (including A&E performance),

cancer waiting times and staffing. It also highlighted infection control compliance rates, stroke

pathway care and sepsis care. As an appendix so the quality and performance report an exception

report was presented to the board to highlight where data was inaccurate. This highlighted where

they had identified poor quality data and provided narrative as to the reasons why.

Supplementing the quality and performance report were a plethora of reports relating to

specific areas of practice. This included for cancer performance, mortality, infection control, and

an update on CQC ‘must do’ and ‘should do’ actions. These reported provided detail on

performance and updates on action plans which clearly identified shortfalls in planned

improvement.

IT systems were not effective to monitor and improve the quality of care, although plans to

resolve this were progressing well. In January the IT team performed a ‘deep dive’ with NHS

Digital to identify how many data quality issues there were within the trust. The team identified

there were 300,000 issues which needed to be resolved to ensure an effective, hospital wide,

system. As of November 2018, this had been reduced to 100,000 issues and new errors identified

(up to 6000 a week) were resolved in a timely way. This included resolving data issues with

referral to treatment national reporting and the management of patient tracking lists. The chief

digital and information officer described the improvement since January as “phenomenal”. The

trust had established a team of therapists, junior doctors and nurses to work with clinicians and the

IT team to make these improvements.

At the time of the inspection, the trust were not submitting data to external bodies as

required, however they were testing data collection for submission from February 2019.

Data quality issues following migration to a new electronic patient records system meant the trust

needed to suspend national reporting of the referral to treatment position (percentage within 18

weeks) and patients who had been waiting for over 52 weeks. This had been suspended since

November 2016. At the time of the inspection the trust were testing the data collection process to

ensure that they were accurate in their submissions. This was to take place for two ‘cycles’ of

submission between December 2018 and January 2019 with the first external submission in

February 2019. Historically there had been concerns over outpatient clinic utilisation, however due

to improvements made to track care utilisation was now averaging at 92%.

To mitigate the risks surrounding patients on waiting lists, the trust had a robust process

for validation. All patients received an administrative validation to ensure that waiting lists

exclude patients who had been seen or completed their pathways. The patients that remained to

be seen had a consultant validation review. Any patient going over their ‘to be seen’ date had a

root cause analysis conducted to identify the reason for the delay. Patients on a cancer pathway

would routinely be discussed at a multidisciplinary meeting. For patients on follow-up waiting lists


beyond their expected follow-up date administrative review was also undertaken to remove

duplicate appointments and the lists were then subjected to clinical validation. This enabled

removal of patients who no longer need follow-up. This process had been successful in

Ophthalmology where 6000 patients were reviewed and almost all given a follow up appointment

based on clinical risk.

Staff did not always have access to the IT equipment and systems needed to do their work

and were burdensome for front line staff. The executive team recognised that the infrastructure

and systems could have been better. Staff in focus groups said that they felt unable to do a good

job on the wards because there were multiple IT systems not working well together. Junior doctors

and consultants felt that they spent more time than they should doing administration. The

management teams felt that the systems poor performance meant they spent time developing

‘work arounds’ and alternative methods to achieve what they needed too which were time

consuming, required validation, and did not give them the confidence in data they expected.

The executive team recognised that access to effective IT systems was a risk and

recognised that they were on a journey to develop this. We were told that the introduction of

electronic prescribing was reaching a point where it could be implemented and that a large project

ongoing was the introduction of nursing documentation on the electronic patient record. Other

projects were completed, such as the introduction of more advance anti-virus software and the

introduction of faster and more reliable devices. There were also system improvements made to

ensure that password resetting became standard. The trust was also piloting the introduction of a

more advanced, and faster operating system on the trust computers.

There were effective arrangements to ensure that notifications were submitted to external

bodies as required. Although there had been some issues with the submission of infection

control data to NHS England. There had been no concerns from external bodies raised with CQC

about the quality of timeliness with regards to incidents. Incidents, including serious incidents,

were reported as required to the NHS national reporting and learning system or the NHS strategic

executive information system. Because of the migration to a patient information record, the trust

found they were significantly underreporting Clostridium difficile infection reports to NHS

improvement. However, the quality of reporting had at the time of the inspection.

The trust was leading in the development of a system wide patient information record and

was working with external stakeholders and other providers to achieve this. The chief digital

and information officer was the executive lead county wide for the development and

implementation of a system wide electronic patient record. This was a collaboration between the

acute trust, community trust, mental health trust, local authority and GP’s to implement one record

throughout the county as part of the integrated care system. Because of this project, the system

had allocated 80% of the county’s IT funding to resolving concerns with the acute trust. The trust

was also working with the Government Communications Headquarters (GCHQ) located in

Cheltenham General Hospital to develop further the cyber security for the county.

The trust achieved a ‘satisfactory’ rating in the self-assessed information governance

toolkit assessment. This is an annual self-assessment which measures assurance, including

management of information, confidentiality and data protection, the quality of information, the

secondary use of information, and a measure for the overall performance. For 2017/2018 the trust


scored 76% compared with a 2016/2017 score of 77%. In 2018 the trust was assessed by NHS

digital which corroborated with the trusts ‘satisfactory’ self-assessment.

Engagement

Staff working operationally on wards felt ill-informed of the winter plan and did not feel

engaged in its development. Staff we spoke with in focus groups were not aware of progress on

the winter plan and had not received communication following initial discussions in April 2017. This

made staff nervous about the coming months over the winter period and were worried about the

trust capacity and ability to keep patients safe during this time. We reviewed evidence of debrief

sessions with operational staff which included lessons learned. Two debrief sessions had been

held in May and June 2018 and the learning had been carried forward, and shared with staff via

the CEO weekly newsletter. The chief operating officer recognised that more could have been

done to engage the staff in the winter plan development and told inspectors there would be a

greater emphasis on engagement for next year’s plan, this included engagement meetings and

planned sessions with affected staff.

Some staff working operationally on wards felt ill-informed of the trust reconfiguration

programme, however we found the trust had taken considerable steps to keep staff involved

through meetings, briefings, newsletters and workstreams, and there was evidence that staff had

been involved in co-designing change. Through focus groups and whistle-blowers, we identified

there was dissatisfaction in some areas of the trust. Staff were nervous about the reconfiguration

and what it would mean for their practice. One medic we spoke with said there “was clear winners

and losers, and the losers had to just put up with it”. Another medic we spoke with said they felt

“that services were being left behind and not given the support needed to develop services”. Some

medics felt disengaged with the reconfiguration programme. The week prior to the well led

inspection over 50 consultants signed a letter to the chief operating officer highlighting their

concerns on patient safety because of reconfiguration. Some staff found the pace of change with

reconfiguration difficult to cope with and this had been recognised by senior leaders. A

management of change toolkit had been developed and we saw evidence of regular meetings,

briefings and newsletters.

There were various staff forums, although some did not work effectively. The trust had set

up a speciality director forum which was well attended and had presence from an executive team

member. The chief executive regularly attended. Consultant staff described to inspectors a

consultant forum, but we were told this was not effective. It was poorly attended and was not held

at times convenient to the consultant body. We were told that when a time change was suggested,

it was not considered as a viable option.

Communication systems such as the intranet and newsletters were in place to ensure staff

had access to up to date information about the work of the trust and the services they

used. There was a programme of releases including a weekly blog from the chief executive,

newsletters on various subjects, videos released on the internet and internal podcasts on specific

themes. Additionally, the board were active on social media and engaged with staff and the public

through this forum. Staff we spoke with were complimentary about the availability of resources

from the executive team. Most staff found the blog produced by the chief executive was a good

source of information and appreciated the focus on celebrating staff achievement which was a

frequent theme, but some found that some messages relayed were not appropriate for a

healthcare environment. Staff commented on the chief executive’s letter said they learnt the


important messages from the trust and found a post on mental health particularly informative and

useful. One member of staff said, “I don’t need to know about her social life when I am stuck in

here all weekend”, another said “it’s sometimes difficult to know she had a good weekend while I

was working hard on a ward”.

Staff in focus groups who worked in lower bandings felt that there had been a change in

focus by the board into developing these staff groups. The chief executive officer attended

healthcare assistant conferences and engaged in conversations and actions which resulted in

actions for the board. Some staff in these bands described the way in which talent management

had led to development and project work and could give evidence of how they had progressed

professionally. Staff said this made them feel valued and supported, where previously they felt

ignored. Staff also commented on the success of the apprenticeships programme in the trust

which was led by senior staff. Because of this focus, the board worked with operational staff to

recruit and empower 145 new staff.

The council of governors had opportunities to raise concerns, risks and issues with

performance and had additional time with the board where required. There was a governor’s

log which could be added too to gain an executive response within several weeks. We were given

examples where issues raised in the log had an impact on the management and direction of

scrutiny from the non-executive directors. Some governors described the openness by the board

as a “miraculous change” since the appointment of the chief executive officer and that where

concerns were raised by the governors “no hint of information was withheld” to give assurances.

Further work was required to support the council of governors to engage with the trust

membership and engagement with patients and the public. The trust website encouraged the

public and staff to contact governors directly, however there was no information available to point

which governor to contact. The only forum for the public and staff to formally engage with the

governors was at the annual general meeting. Some governors shared messages in local parish

magazines, and others had considered doing public drop in sessions but outputs from these were

limited. Governors also recognised that they were not doing enough walk arounds and were not

visible enough on wards on in public areas.

However, the council and the trust board had plans to improve engagement. We were told of

plans to address engagement, and the lead governor, the CEO and chair all acknowledged this as

an area of focus. Governors discussed a will to make changes to improve engagement. One said,

“we want to put the time and effort in”. Some discussed how they were using social media to share

messages. One said “I feel like I am able to capture a different audience. The trust had recognised

a learning need for governors around social media and had developed training on how they could

utilise it within their role.

There were positive and collaborative relationship with Gloucestershire Managed Services

and the establishment of the subsidiary company was managed well. As of 1 April 2018, staff

from estates, facilities ad sterile service (such as porters, cleaners, and maintenance teams) were

employed by GMS rather than by the trust. During this process the trust board considered the


views of staff who were consulted with extensively as part of the process. Questions and concerns

raised by staff during this period shaped the final proposal which was agreed upon.

Learning, continuous improvement and innovation

There was a fully embedded and systematic approach to improvement. The Gloucestershire

Safety and Quality Improvement Academy (GSQIA) was established in 2015 to increase quality

improvement capability and capacity to embed continuous quality improvement. Its original aim

was to deliver a programme of training and support to the trust and building an external reputation

in the field of quality and safety improvement. The trust established a quality governance

framework with a set methodology to ensure oversight, quality control and safety was assured.

The quality governance framework gave the board assurance that the quality of care was

fundamental to continual improvement projects in the trust. This framework empowered front line

staff with the tools to support a change and implement a quality improvement project.

Staff we spoke with said that the GSQIA had created a recognisable brand within the trust,

with some describing it as a “social movement”. Throughout all the focus groups there was a

narrative on quality improvement and innovation. Staff at all levels were engaged in the process

and could give examples where quality of care for patients had improved because of quality

improvement projects. This was supported by an active social media presence through the

hashtag ‘journey to outstanding’ to recognise the achievements of projects and innovations from

staff. This hashtag was used widely by operational staff and the executive team. We asked staff in

all focus groups about quality improvement and found staff were overwhelmingly positive about

the process and the outcomes it generated. For example, one matron said, “there is lots of energy

behind quality improvement, and lots more opportunities to develop”. Due to the number of health

care assistants in the trust wanting to perform quality improvement projects a ‘bronze study day’

had been established to share information and support quality improvement projects. One general

manager said that “projects needed to sit with clinicians and not with managers, with quality

improvement anyone can go and do it. It adds strength as expert individuals can drive change”.

Another member of staff said, “it gives staff the opportunity to engage in something they are

passionate about”.

Improvement was seen as the way to deal with performance and for the organisation to

learn and could clearly evidence improvements to patient care. Outcomes from quality

improvement projects were having a positive impact on patients and the quality of care they were

receiving. Examples included a project to reduce the incidents of bloodstream infections through a

central venous catheter which reduced incidence by 50% improving patient safety. Another project

looked to reduce the amount of hospital acquired flu and found that over the winter period of

2017/18 they reduced this by 50% and calculated that flu associated deaths were dramatically

reduced. Another project looked at a way of facilitating partners to stay overnight in four bedded

bays on the maternity ward to improve the patient experience.

Improvement methods and skills were available and used across the organisation to

empower staff to lead and deliver change. The trust had developed a training package (bronze,

silver and gold) to establish sound knowledge and understanding of quality improvement. Bronze

training was a half day introduction to quality training. Silver training was a one-and-a-half-day


training programme which facilitated and supported staff to develop a project. Gold training was a

five-module training session which taught staff to facilitate and manage improvement programmes

autonomously.

There was consistent use of a recognised improvement methodology. In September 2018

there were 1537 staff trained to bronze level, 97 staff trained to silver level and 45 staff trained to

gold level. These were spread throughout all divisions within the trust with the most being within

medicine and surgery. There were 171 rotation junior doctors who were trained to bronze and 17

trained to silver. The uptake of training surpassed the trusts expectations and was on an

increasing trajectory with more training sessions being delivered regularly.

The work conducted by the trust on quality improvement had been presented nationally

and had received national and international recognition. The Kings fund stated that “what is in

the water here? I’ve not had an experience in these visits as exciting as what is happening in

Gloucestershire. I don’t think I’ve seen anything quite like this… It’s really special”. In 2018 the

academy was shortlisted for two Health Service Journal awards for safety and value.

Safe innovation was celebrated. Following the graduation of staff from the training programme

the trust holds an ‘academy award event’ which identifies the best quality improvement initiative,

best presentation, most innovative improvement, and best poster. These events were widely

attended by staff and were well advertised within the trust. Examples of winning projects included

the development of a support group for patients following critical illness in Gloucestershire, and a

project on reducing the amount of time babies and mothers were separated when receiving

intravenous antibiotics on the neonatal intensive care unit.

Complaints process overview

Information on the complaints and concerns reported to the trust during each quarter was

presented to the quality and performance committee and reported annually to the trust board. An

update of lessons learned was included in the report.

The trust was asked to comment on their targets for responding to complaints and current

performance against these targets for the last 12 months.

Question In days Current

performance

What is your internal target for responding to complaints? 3 98%

What is your target for completing a complaint 35 59%

If you have a slightly longer target for complex complaints

please indicate what that is here N/A N/A


Number of complaints resolved without formal process in the

last 12 months? 2,569 N/A

(Source: Routine Provider Information Request (RPIR) – Complaints Process Overview tab)

Number of complaints made to the trust

The trust received 1,030 complaints from April 2017 to March 2018. Surgery received the most

complaints with 306 complaints, accounting for 29.7% of the total received.

A breakdown by core service can be seen in the table below:

Core Service Number of

complaints

Percentage of

total

Surgery 306 29.7%

Medical care (including older people's care) 210 20.4%

Urgent and emergency services (A&E) 157 15.2%

Outpatient services 145 14.1%

Other 79 7.7%

Gynaecology 39 3.8%

Services for children and young people 35 3.4%

Maternity 32 3.1%

Diagnostic imaging 24 2.3%

End of life care 2 0.2%

Critical care 1 0.1%

(Source: Routine Provider Information Request (RPIR) – Complaints tab)

The complaints team often felt overwhelmed by the workload they were under. We spoke

with some of the complaints team who said that the levels of work expected of them was

consistently too high. They recognised that the team had undergone significant understaffing and

that improvements were being made to improve capacity and staff wellbeing. The Complaints

team consists of 2.9 WTE band 6 complaints managers; responsible for the coordination of staff

investigating. The final response to the complainant was supported by 1WTE band 4 and 1WTE

band 3 administrators. During 2017/18 the complaints managers each dealt with an average of

356 new complaints. During 2017/18 the Trust received 1031 complaints which equates to an

average of approximately 20 complaints received per week. This is an increase of approximately

13% against the number of complaints received during 2016/17 (913).


Compliments

From April 2017 to March 2018, the trust received a total of 5,733 compliments.

A breakdown by core service can be seen in the table below:

Core service Number of compliments Percentage of total

Medical Care (including older

people's care) 2,078 36.2%

Surgical 1,226 21.4%

Urgent and Emergency services 966 16.8%

Maternity 476 8.3%

Other 269 4.7%

Services for children and young

people 260 4.5%

Diagnostic imaging 243 4.2%

End of life care 133 2.3%

Critical care 58 1.0%

Gynaecology 12 0.2%

Outpatients 12 0.2%

(Source: Routine Provider Information Request (RPIR) – Compliments)

The trust was one of the largest recruiters to clinical trials in the South West. We were given

a plethora of examples throughout the core service and well-led inspections regarding the trust

involvement in research. Between November 2017 and October 2018 82 trials opened to

recruitment, with an additional 100 clinical trials already open. Within these trials 1,800 participants

were recruited. The largest cohort of patients recruited to trials were for anaesthesia, perioperative

medicine and pain management with 56% of all patient recruited in the surgical core service.

The trust was working collaboratively with the West of England Genomics Partnership to

participate in the 100,000 genomes project. The project aims to sequence 100,000 genomes

from around 70,000 people by the end of 2017 in 13 sites across England. Eligible participants are

NHS patients with a rare disease, plus their families, and patients with certain cancers. A major

aim is to create a new genomic medicine service for the NHS and to use this data to improve

patient care.


The trust encouraged staff to get involved in clinical research. The clinical research team

encouraged staff to be involved in clinical research through easy access to training, and regular

communications from the research team. The trust was able to offer National Institute for Health

Research training in-house with flexible days and time available. Additionally, they provided a

‘principle investigator masterclass’ for those seeking further training. The research team had a

communications team member who ran sessions for staff informing them of clinical research and

regularly published information regarding trials in the trusts magazines and newsletters. A

research and innovation forum was available for staff to attend to share ideas regarding research.

The research team worked with charities and commercial organisations to ensure a

sustainable future for research in the trust. The budget for clinical trials was allocated on an

annual basis by the trust and the South West Research Institute. Additional funding was provided

through taking part in commercial trials, crowd funding, and working with charities. The trust was

also working with the University of Gloucestershire to develop the hospitals into a university

hospitals trust status, although staff acknowledged they were at the start of this journey.

The trust had invited external bodies into the hospitals to assess them against set criteria

to achieve accreditation. NHS trusts can participate in accreditation schemes whereby the

services they provide are reviewed and a decision is made whether to award the service with an

accreditation. A service will be accredited if they are able to demonstrate that they meet a certain

standard of best practice in the given area. An accreditation usually carries an end date (or review

date) whereby the service will need to be re-assessed to continue to be accredited.

The table below shows which of the trust’s services have been awarded an accreditation.

Accreditation scheme name Service accredited

Joint Advisory Group on Endoscopy (JAG) Medicine (including older

people's care)

Clinical Pathology Accreditation and its successor Medical

Laboratories ISO 15189

Diagnostic Imaging

(additional service)

CHKS Accreditation for radiotherapy and oncology services

Outpatients/ Medicine

(including older people’s

care)

MacMillan Quality Environment Award (MQEM)

Outpatient/ Medicine

(including older people’s

care)

(Source: Routine Provider Information Request (RPIR) – Accreditations tab).

External organisations had recognised the trust’s improvement work and some areas had

received accreditation JAG accreditation highlights that the gastrointestinal endoscopy

service was of a high quality. The external body carried out a planned review and inspection of


facilities, policies, procedures and equipment against national best practice standards. Medical

laboratories ISO 15188 accreditation highlights high quality and competence for quality

management systems in the medical laboratory. CHKS accreditation highlights the achievements

of the oncology service in the delivery of patient safety, quality improvement, leadership,

governance and effective management, developing staff and managing risk. The MQEM is a

framework assessing if cancer care environments meet the standards required by people living

with cancer.


Acute services

Urgent and emergency care

Facts and data about this service

Context Gloucestershire Hospitals NHS Foundation Trust runs two emergency departments, providing

urgent and emergency care and treatment to the people of Gloucestershire. The emergency

departments are located at Gloucestershire Royal Hospital and Cheltenham General Hospital.

The two hospitals share a divisional management team including Director of Unscheduled Care,

Deputy Director of Unscheduled Care, Capacity and Flow, Specialty Director/Deputy Chief of

Service, Clinical Lead, Matron and an Assistant General Manager.

Gloucestershire Royal Hospital Gloucestershire Royal Hospital (GRH) has an emergency department. The hospital provides full

emergency department services for major and minor illness and injury. The department

comprises of seven areas:

Two major injury areas, with a total of 24 cubicles

A four-bay resuscitation unit, including one bay for paediatrics

Three paediatric assessment rooms and a separate waiting area

Three assessment bays for minor injuries

An interview room/mental health assessment room

A GP consultation room (for streaming GP)

The hospital has trauma unit status, which means they receive emergency trauma patients from

the local area, some of whom arrive by helicopter. The unit feeds into the Major Trauma Centre at

Southmead Hospital.

A streaming GP is based at the hospital. This supports a primary care streaming process, which

filters approximately 25 patients per day who are suitable for management by a GP.

Cheltenham General Hospital

Cheltenham General Hospital (CGH) has an emergency department, which is open from 8am to

8pm. Outside of these hours, the department operates as a nurse-led minor injuries unit. The

department comprises of:

A major’s area with a total of six cubicles

A two-bay resuscitation unit, including one bay for children

Four assessment rooms for minors and an eye treatment room

Mental health assessment room


There is no children’s emergency department at Cheltenham General Hospital, therefore only

children with minor injuries and illness can be seen. Those with more serious illness or injury will

be asked to attend the emergency department at Gloucestershire Royal Hospital.

Activity and patient throughput Total number of urgent and emergency care attendances at Gloucestershire Hospitals

NHS Foundation Trust, compared to all acute trusts in England, July 2017 to June 2018

From July 2017 to June 2018 there were 143,064 attendances at the trust’s urgent and

emergency care services, as indicated in the chart above. Of these, 26,294 were children.

(Source: NHS England) Urgent and emergency care attendances resulting in an admission

The percentage of emergency department attendances at this trust that resulted in an admission remained similar in 2017/18 compared to 2016/17. In both years, the proportion was higher than the England average. This is likely to be because neither of the hospitals have an observation


ward, where patients requiring continued monitoring can be cared for. If this is required, most patients will be admitted to a short-stay ward. (Source: NHS England) Urgent and emergency care attendances by disposal method, from June 2017 to May 2018

* Discharged includes: no follow-up needed and follow-up treatment by GP ^ Referred includes: to A&E clinic, fracture clinic, other OP, other professional # Left department includes: left before treatment or having refused treatment

(Source: Hospital Episode Statistics)

Is the service safe?

Mandatory training

The service provided mandatory training in key safety systems and processes; however,

not all staff had completed it. Compliance with training targets was particularly poor for

medical staff. The emergency department had a good recording system for mandatory training

which highlighted when training was needed and provided a good oversight of training

completion rates. Staff knew the training modules they needed to complete and were e-mailed

when training was due. Staff could also access their records on the intranet. This told them what

they had completed and what was outstanding.

Mandatory training completion rates The trust set a target of 90% for completion of mandatory training. Nursing Staff The 90% training target was met for five of the 10 mandatory training modules for which

registered nursing staff were eligible. A breakdown for the 12 months ending June 2018 is

shown below:

Name of course Staff

trained Eligible

staff Completion

rate Trust

Target Met

(Yes/No)

Equality and Diversity 205 209 98% 90% Yes

Medicine management training 195 209 93% 90% Yes


Health and Safety (Slips, Trips and Falls) 194 209 93% 90% Yes

Fire Safety 1 Year 192 209 92% 90% Yes

Adult Basic Life Support 192 209 92% 90% Yes

Infection Control (Role pathway) 187 209 89% 90% No

Manual Handling - Object 186 209 89% 90% No

Information Governance 183 209 88% 90% No

Conflict Resolution 169 209 81% 90% No

Manual Handling - People 148 209 71% 90% No Medical Staff The 90% target was met for none of the nine mandatory training modules for which

medical staff were eligible. Medical staff worked across both sites, so compliance is only

presented at trust level. A breakdown for 12 months ending June 2018 is shown below:


trained Eligible

staff Completion

rate Trust

Target Met

(Yes/No)

Equality and Diversity 112 132 85% 90% No

Manual Handling - People 100 132 76% 90% No

Health and Safety (Slips, Trips and Falls) 99 132 75% 90% No


Fire Safety 1 Year 94 132 71% 90% No

Adult Basic Life Support 94 132 71% 90% No



Manual Handling - Object 89 132 67% 90% No They told us there were difficulties keeping compliance levels at trust standards due to

the turnaround of medical staff rotating through the department. Some on the list for

mandatory training are bank staff who generally have less opportunity to complete modules,

however they are expected to be up to date.

Nursing Staff Gloucestershire Royal Hospital urgent and emergency care department – Nursing Staff

The 90% target was met at Gloucestershire Royal Hospital for five of the 10 mandatory

training modules for which registered nursing staff were eligible. A breakdown of

compliance for mandatory training courses for the 12 months ending in June 2018 is shown

below:

Name of course

Staff trained

Eligible staff

Completion rate

Trust Target

Met (Yes/No)











Manual Handling - People 82 117 70% 90% No Cheltenham General Hospital urgent and emergency care department – Nursing Staff

The 90% target was met at Cheltenham General Hospital for eight of the 10 mandatory

training modules for which registered nursing staff were eligible. A breakdown of

compliance for mandatory training courses for the 12 months ending in June 2018 is shown

below:


trained Eligible

staff Completion

rate Trust

Target Met

(Yes/No)



Manual Handling - Object 55 57 96% 90% Yes


Information Governance 54 57 95% 90% Yes


Infection Control (Role pathway) 54 57 95% 90% Yes




Safeguarding

Staff acted appropriately to protect patients from abuse. Most staff had received training on how to recognise and report abuse and did not follow the processes in place to identify those at risk. Training rates were slightly better at Cheltenham General Hospital for nursing staff than it was at Gloucestershire Royal Hospital. Staff were mostly up to date with training for staff designed to protect people from abuse.

The trust set a target of 90% for completion of safeguarding training and compliance for medical

above this target. The target was not always met by nursing staff.

Gloucestershire Royal Hospital urgent and emergency care department – Nursing Staff


trained Eligible

staff Completion

rate Trust

Target Met

(Yes/No)

DOLS awareness 85 95 89% 90% No

MCA awareness 85 95 89% 90% No

Safeguarding Adults Awareness 81 95 85% 90% No

Safeguarding Adults Level 1 80 95 84% 90% No

Safeguarding Children Awareness 81 95 85% 90% No

Safeguarding Children Level 2 88 95 93% 90% Yes

Cheltenham General Hospital urgent and emergency care department – Nursing Staff


trained Eligible

staff Completion

rate Trust

Target Met

(Yes/No)

DOLS awareness 43 46 93% 90% Yes


MCA awareness 43 46 93% 90% Yes

Safeguarding Adults Awareness 44 46 96% 90% Yes

Safeguarding Adults Level 1 40 46 87% 90% No

Safeguarding Children Awareness 43 46 96% 90% Yes

Safeguarding Children Level 2 42 46 91% 90% Yes Medical Staff - Consultants


trained Eligible

staff Completion

rate Trust

Target Met

(Yes/No)




Safeguarding Adults Level 1 16 17 94% 90% Yes



Medical Staff – Trainee


trained Eligible

staff Completion

rate Trust

Target Met

(Yes/No)




Safeguarding Adults Level 1 25 27 93% 90% Yes



Policies were available to guide staff on how to protect people from abuse. There were

policies available on the internal computer system relating to the safeguarding of adults and

children. These were up to date and referred to relevant legislation and guidance.

Although some training was delivered through e-learning, there were annual face-to-face

updates which all staff attended. This ensures they have a good foundation to build on when

completing the eLearning training. Staff also attend annually a child protection response and

recognition course which was run by the Gloucestershire multi-agency safeguarding board.

Staff in the emergency department were aware of their child and adult safeguarding

responsibilities and the process for referring patients was well understood and was easy to

follow. Staff could complete referrals on-line or on paper. However, staff told us they couldn’t

always access the departments safeguarding leads straight away, but they were available to

review patients and support staff with complex decision making.

Risk assessments for patients were completed on a clinical indication basis and if they

were felt to be necessary. This meant that not all patients required one, but those at greatest risk

did. During the time we were on inspection we found that most who required risk assessments,

had them. However, there was one occasion where this should have been done but didn’t. We

raised this with the staff in the department who quickly responded to ensure they were safe.

There were posters located around the department, signposting patients to helplines for

those experiencing domestic violence. The department used DASH (domestic abuse, stalking


and harassment) risk assessments to assess the risk to people suffering from violence and

aggression at home.

Cleanliness, infection control and hygiene

Regular infection control audits were completed and fed back to the matron. These were

discussed in the infection control committee, held six-weekly. Audits were completed by the

company contracted to provide the cleaning service, and separate environmental audits were

conducted by the matron. Comprehensive cleaning audits were conducted in the department.

These showed that cleaning responsibilities held by nursing staff scored lower, compared to

cleaning and estate staff. The issues mostly related to the cleaning of equipment.

Cleaners were working within the department at all times during our inspection. The

cleaning schedule identified areas to clean and how frequently, including daily and weekly tasks.

Cleaning schedules were on display and there was evidence of daily checks.

There were systems to ensure clinical waste, including sharps, was appropriately disposed

of. Clinical waste was correctly segregated and disposed of regularly. We checked sharps bins

and they were assembled correctly. They were dated, signed and were not over-filled.

Gloucestershire Royal Hospital

There were systems and process in place to manage infection control risk well. Although, there were occasional times where opportunities for good infection management were missed. Although most staff followed good hygiene processes, there were some occasions when staff did not follow recommended hand hygiene processes clean equipment between patients. During the inspection most staff we observed the ‘bare below the elbow’ rule and wore personal protective equipment, such as gloves and aprons. Staff washed their hands and we saw them using alcohol hand rub between patients. We observed one doctor from another department, assessing a patient, who was not bare below the elbow.

Equipment was mostly cleaned in line with best practice and trust policy. Mattresses and chairs were generally in good condition and wiped-clean. Flooring was appropriate and mostly in good condition. Equipment was generally clean and identified as such using green ‘I am clean’ stickers. We found one treatment room in the children’s department with an empty alcohol hand rub dispenser; this area was in use for patient treatment. We raised this with staff and it was re-filed. On one occasion we saw blood on a cannula tray in a treatment room that had not been used that day.

Audit results around infection control were mixed. Over the five months of results submitted, overall scores ranged from between 50% and 80%, with doctors being the lowest scoring staff group at 53%. Bare below the elbow compliance was between 90-100%.

Floor cleaning in department and the cleaning of cubicles could have been better. Although

floors were cleaned between patients, this focused on areas of most footfall. Areas under the

beds and sinks had ingrained dirt. There were instructions for curtains to be changed if they were

soiled and all curtains were changed once a quarter. There were some occasions when the

environment was not clean or tidy for patients. We checked cubicles ready for patients, we found

bits of paper, tissue and dirt on the floor in one cubicle, in another cubicle the trolley was dusty

and dirty, there was no paper (used for patients to lie on) replaced on the trolley, following the

last use and there were three dirty coffee cups on the side. Medical staff brought a patient to this

cubicle and asked the patient to sit on the couch. The patient was examined without the cubicle

being cleaned.



The service controlled the infection risk well. Staff maintained good standards of hand hygiene and cleaned clinical areas between patients.

Staff observed the ‘bare below’ the elbow rule and wore personal protective equipment, such as gloves and aprons. Staff washed their hands and used alcohol hand rub between patients. Hand hygiene audits had been completed on a range of staff groups; we reviewed the last three months of results which had each scored 100%.

There were instructions for curtains to be changed if they were soiled and all curtains were changed once a quarter. Records were available to show when this had been done.

Comprehensive cleaning audits were conducted in the department. These were completed by the company contracted to provide the service. In recent audits for the emergency department had achieved high scores. During our inspection we did not have the opportunity to observe the care of patients with infectious illness.

Environment and equipment


Environments were appropriate to observe patients. There was a seated area for waiting adult

patients, with plenty of seats available, where patients could be observed by reception staff.

There were five assessment areas in the children’s area and there was a dedicated resuscitation

bay for children. The minors, majors and resuscitation areas were well equipped. All equipment we

checked was well maintained and had recently been serviced. There was a resuscitation area with

four bays, one of them designed to support the care of children.

The department made the environment as safe as possible for patients during periods of crowding and patients were moved to different areas depending on their risk and status within the department. A corridor, known as corridor three, which was often used as a place for patients who had a decision to admit. The use of this area had significantly reduced over the last 12 months with the average number of patients using it a day going down from 16 to six. There were surges in arrivals which sometimes meant a queue built quickly, but improved admission pathways and support from the acute medical teams meant that the queue also reduced quickly.

There was appropriate equipment in place if a patient required help. At our last inspection we told the hospital they should consider how they respond to patients needing help in the queue, without a call bell to press. The hospital had bought call bells, which were located on the wall next to the patient, so they could call for help. Unfortunately, the call bell system was broken at the time of our inspection and had not been working for a couple of weeks. We were told that one of the doctors was arranging for it to be fixed but no one knew a timescale for this to be completed.

Children waited in an area that was physically separate from the adults’ waiting area,

however it was not always secure. Although the areas fully complied with ‘Facing the Future:

Standards for children in emergency care (standards which ensure design safety) we found that

partition doors between the children’s area and the rest of the department and the wider hospital,

were routinely left open. We found on many occasions, that any adult could walk from the main

hospital corridor to the children’s waiting area, which meant that children could be at risk of harm.

If unwatched, children could wander from the children’s area into the adult treatment areas. We

raised this as a concern, and by the end of the inspection, processes had been put in place to

ensure they were closed and access was only given by staff.


There was sufficient workspace, seating and computer terminals for medical and nursing

staff to update notes and discuss care in the majors area. There were two major treatment

areas, known as majors one and majors two, which, combined, provided 24 cubicles. They were

connected through an archway and there was limited line of sight between the two.

There was an office area, which provided a confidential space where private conversations

or telephone calls could take place. The office, which was located next to the ambulance

entrance, was also used to book in patients arriving by ambulance in the afternoon and evening.

Concerns raised during the last inspection about the environment had been addressed.

During our last inspection we raised concern that the layout of the department meant there was no

face-to-face assessment of patients during handover by the nurse co-ordinator, who was based in

majors one. This was because ambulance trolleys often queued around a corner where the patient

could not be seen from the nurses’ station in majors one. We also raised a concern that queuing

ambulance trolleys sometimes blocked the door to the resuscitation area. These two issues had

now been resolved by having a designated receiving nurse in majors two, in addition to the nurse

co-ordinator. Ambulance crews now stopped in majors two (located next to the ambulance bay)

and queues were confined to that area, overseen by a corridor nurse and a health care assistant.

We had a remaining concern about the nurse co-ordinator being based in a separate area to the

majority of queuing patients, as it limited the co-ordinator’s knowledge and oversight of the

patients in the department. However, overall, the new arrangement was safer and reduced the risk

to patients.

There was a cubicle designated for the assessment of patients arriving by ambulance or for

patients needing to see a doctor, for whom a bay had not yet become available. This cubicle

was usually ringfenced for this purpose, even when the department was busy. At times of severe

pressure, the cubicle could be used to accommodate patients and was sometimes used for

deceased patients, as it had a door that could be closed. When this happened there was an

immediate impact on the department’s ability to assess and treat patients who were waiting in the

queue.

The CT scanner and X- ray department were located close to the emergency department.

This meant unwell patients had rapid access to radiological investigations.

There was a designated assessment room in the major’s area for patients presenting with

mental health problems and the trust had completed some work to make the mental health

assessment room comply with guidance. Furniture was suitable and there was an alarm

system and the room had two outward opening exits. However, one exit opened into the children’s

waiting area which was inappropriate, as patients had unsupervised access to the children’s

waiting area. The room was safe in most other ways for the care and assessment of patients

suffering from mental health illness. The room mostly complied with the standards recommended

by the psychiatric liaison accreditation network (PLAN), except the design of the doors did not

protect patient’s privacy as there were no shutters. It contained several chairs and a table that

could not be lifted, there were no ligature points and there were two doors in case one became

barricaded. There was a window on each door to allow staff to see into the room and the room

provided the patient with privacy and a quiet space, whilst still being located within the emergency

department.

Equipment was maintained and serviced regularly. Regular checks were completed by staff to

ensure that the equipment and consumables needed to treat patients were readily available,

including in the resuscitation area. When a piece of equipment or the premises needed repair,

staff completed an electronic log to report faulty equipment or environmental issues. Staff reported


this system worked well and repairs took place promptly. We found two maintenance concerns

during our inspection, a blocked toilet and a broken ceiling tile. These were reported while we

were there, and the maintenance team responded very quickly.


The service had suitable premises and equipment. There was an adult waiting area and separate children’s waiting area with a television, books and toys There were two resuscitation bays, one of which had been designated for the care of children and

was equipped appropriately.

There were trolleys with equipment and consumables to deal with time-critical

emergencies. There was a resuscitation trolley and chest drain trolley. These were wrapped in

plastic wrap to ensure they remained clean and they were date-tagged indicating the date of the

last check. They were checked daily, and a checklist was signed to confirm the checks were

complete. The difficult airway trolley was checked by theatre staff and was kept unwrapped.

Checks were completed on most days but there were five occasions in the last three weeks when

no checks had been completed. This posed the risk that equipment required in an emergency may

not be ready for use.

Clinical areas were appropriately equipped to provide safe care. Equipment was generally fit

for purpose and regularly serviced, although we found an eye torch that was overdue a service.

There was a system for the repair of clinical equipment and this ensured broken equipment was

repaired or replaced efficiently.

During our inspection we inspected an eye treatment room that was generally untidy and

not clean, with discarded pieces of paper, dirt trapped in the corners of the equipment

trolley and dried blood on the sharps tray. In one of the minor’s assessment rooms there was

broken plastic on a trolley, a paper towel holder kept together by a plaster, flaking paint and dust

on the window sills.

The storage room used to store equipment used to apply plaster casts was dirty and

untidy. Staff told us the expectation was for the equipment to be cleaned and returned after use.

However, there was plaster and water left in the buckets and dry plaster over the sink area,

instruments and other equipment stored in the same area. There was also plaster on the floor and

we watched staff walk through this and track plaster through the corridor. We also found a mop

head discarded on the floor, both cupboard doors were left open next to the entrance where

people could hit their head. Inside this cupboard there were a messy pile of leaflets, we picked one

off the pile and several of them fell out of cupboard into the sink. There was a second sink area

with a broken edging strip behind the sink with dirt trapped underneath, likely to harbour bacteria.

In the same area there were a number of nitrous oxide cylinders loose on the floor, rather than in

racks. This posed a risk of injury and potential theft/misuse.

In the sluice area, we found tiles falling off the wall behind the sink and two large holes in the plaster wall. The areas we found in disrepair did not directly affect clinical care, however there was potential risk of harm to staff or damage to equipment.

There was a system for the identification and repair, cleaning or maintenance of premises. However, many of the issues we found had not been identified. There was a plan to repair and protect the holes in the wall of the utility area, which had been damaged by wheeled bins.

Assessing and responding to patient risk


Patient risks were not always managed quickly and effectively, and staff did not consistently complete risk assessments and hourly safety checklists. Whilst patients were checked regularly when in the department, not all patients received an initial assessment with the expected 15-minute timeframe and there were often delays in commencing treatment. However, reception staff responded quickly to patients who arrived in distress or pain. In one case we observed, a doctor was alerted, and the patient taken through to triage and into majors. Ambulance Handovers

Ambulance handovers had improved since the last inspection and significant delays were

now scarce. Emergency Departments are expected to accept handover of patients from

ambulance crews within 15 minutes. Handover of patients arriving by ambulance was reported

trust-wide and data collected on those taking over 30 minutes and those taking over 60 minutes.

The hospital had identified that the delays to ambulance handovers happened at the time of peak

congestion in the early evening. Individual hospital performance was not available.

Overall, performance had improved since our last inspection. In 2017/18 there were 506

breaches over 30 minutes and 15 breaches over 60 minutes (known as black breaches).

However there had been an increase over the summer. The number of breaches were reported

as:

February: 44 (>30min), 3 (>60min)

March: 49 (>30min), 3 (>60min)

April: 30 (>30min), 1 (>60min)

May: 25 (>30min), 3 (>60min)

June: 44 (>30min), 1 (>60min)

July: 58 (>30min), 0 (>60min)

August: 68 (>30min), 2 (>60min)


Approximately two thirds of delayed handovers were at Gloucestershire Royal Hospital

and there had been a deteriorating trend. During our inspection we observed the handover

process and spoke with ambulance crews. The time to handover was noticeably extended by

requesting the ambulance crew book the patient in at reception before handover. Ambulance

crews told us when reception was busy, they could sometimes wait for some time. This was

assisted in the evening when a separate designated ambulance booking-in desk was opened

next to the ambulance entrance.

The ambulance turnaround time reflects the time from arrival to the time the ambulance is

made ready and available again for the next call. The national target is 30 minutes (15

minutes for patient handover and 15 minutes to make ready). There was a stable trend in the

monthly percentage of ambulance journeys with turnaround times over 30 minutes at

Gloucestershire Royal Hospital.

Ambulance: Number of journeys with turnaround times over 30 minutes – Gloucestershire Royal Hospital


Ambulance: Percentage of journeys with turnaround times over 30 minutes - Gloucestershire Royal Hospital

(Source: National Ambulance Information Group) Cheltenham General Hospital Approximately one third of the handover delays at the trust were at Cheltenham. Staff told us that handovers were rarely an issue unless ambulances were diverted to them from Gloucestershire Royal Hospital. During diverts staff found queues at Cheltenham General Hospital could build quickly due to the smaller size and capacity of the department. We were not provided with data to corroborate this. Data was also unavailable for ambulance turnaround times at Cheltenham General Hospital. We observed the routine completion of hourly board rounds between the senior nurse and

senior consultant. Patients were discussed, and joint decisions were made about clinical priority

and progression of care.

Number of black breaches (Trust wide data) From July 2017 to June 2018 the trust reported only 15 “black breaches”, with an increase over the winter period. These breaches were all due to overcrowding/congestion. This shows performance that was significantly better than other trusts and highlights a good working relationship with the local ambulance service. A “black breach” occurs when a patient waits over an hour from ambulance arrival at the emergency department until they are handed over to the emergency department staff.


(Source: Routine Provider Information Request (RPIR) - Black Breaches tab)

Initial Assessment The median time from arrival to initial assessment for patients arriving by ambulance at

both hospitals was about the same as the overall England median in the period from July

2017 to November 2017. Performance then improved and was lower (better than) than the

England median in the period until July 2018. The percentage of all patients (including self-

presenting and those arriving by ambulance) receiving an initial assessment within 15 minutes

was consistently between 85-90% across both hospitals.

Median time from arrival to initial assessment (emergency ambulance cases only) from

July 2017 to June 2018 at Gloucestershire Hospitals NHS Foundation Trust

(Source: NHS Digital - A&E quality indicators)


Over the six months from March 2018 to August 2018, the average time to initial

assessment was six to eight minutes. In majors the monthly percentage of patients assessed

within 15 minutes ranged from 90.8% to 92.8%. In minors the monthly percentage ranged from

87.3% - 91.1%.

Patients arriving by ambulance were booked in and then the ambulance crew handed the

patient’s information over to a designated nurse who sat at the nurses’ station in ‘majors

2’. Ideally the patient would then be allocated a cubicle and a full handover was given to the

receiving nurse, who completed an initial assessment, including an initial set of observations.

Self-presenting patients who arrived at reception with concerning symptoms were seen

immediately. Receptionists went to the nurses’ station in the major’s area to ask for assistance

0

1

2

3

4

Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18


and we saw help provided quickly on several occasions. Reception staff did not have any training

or guidance tools to recognise ‘red flag’ symptoms but told us they used their experience and

personal judgement to identify patients of concern. Guidance from the Royal College of

Emergency Medicine does not suggest staff require specific training for this task, but it does

recommend staff use a ‘well defined’ list of symptoms to identify those in need of immediate help.

A streaming nurse also sat in the emergency department reception area from 10am until

8pm. The streaming nurse observed patients booking in and in some cases invited them over to a

different area of the reception desk so that they could be directed to the best place for their care.

This decision-making was rapid and did not involve a physical assessment, but this was arranged

with the triage nurse if appropriate. Patients could be re-directed to other locations for their care,

such as their own GP if their problem was non-urgent, a GP who worked in the emergency

department, or the acute medical unit for patients who had already been referred by their own GP.

This helped patients by reducing the waiting times for those presenting with emergency problems.

For those referred by their GP, a set of clinical observations were taken and only those with a

NEWS (national early warning score) of three or below would be sent to the ward. Those with a

higher score would be assessed first in the emergency department.

Self-presenting patients were called through from the waiting area to be assessed by a

triage nurse, who established their clinical priority. We observed patients being triaged

promptly within 15 minutes of registering. Triage was always undertaken by a registered

healthcare professional, who used the Manchester triage tool, a recognised tool for the

prioritisation of patients. During the assessment they took appropriate observations, including pain

scores, and gave analgesia when it was needed.


Over the six months from March 2018 to August 2018, the average time to initial

assessment was 8 to 9 minutes. In majors the monthly percentage of patients assessed within

15 minutes ranged from 88.7% to 90.6%. In minors the monthly percentage ranged from 85.1% -

90%.

Self-presenting patients booked in at reception and waited to see a triage nurse. There was

no streaming system in operation in the department. If patients booked in with concerning

symptoms the receptionist would alert a nurse and patients were seen immediately. No specific

training or guidance was provided to reception staff to determine which patients needed to be

seen urgently, but triage staff were trained to use the Manchester Triage Tool.

Managing Clinical Risk

Gloucestershire NHS Foundation Trust Staff at both sites responded well to the changing risks to patients, including deterioration

in their condition. Whilst queuing was not uncommon at either hospital, we saw nurses

adjusting the priority of some patients and finding space for urgent assessment when it was

needed. Doctors made themselves available for advice or to provide analgesia when needed and

senior medical advice was available at all times.

Staff monitored patients whilst in the emergency departments to assess their risk of

deterioration by using a patient safety checklist. This is an evidence-based tool that specifies

the clinical tasks that should be undertaken in each hour of the patient’s stay and reduces the risk

of important elements of care being overlooked, such as hydration and medicines. The Trust also


used a national early warning score (NEWS) which was taken on arrival and throughout the

patient’s stay in the department. This is a system of taking physiological measurements and

calculating the risk that their condition is serious, such as in cases of sepsis. The newer version of

the system (NEWS2) was not yet in use.

Patients suspected of having sepsis were screened on arrival and managed using a

recognised sepsis pathway ‘sepsis six’. There were different pathways for adults and children

of different ages and a separate guideline for neutropenic patients. Staff told us they were

concerned at not having information related to blood glucose available during patient

assessments. However, the screening process highlights a venous blood gas measurement which

provides this measurement.

The trust had a system to reduce the risk of missed fractures. After initial diagnosis by the

treating doctor, all x-rays produced a radiology report. These were routinely reviewed by a

consultant who re-called any patients with missed fractures.

There were tools available for doctors to support them in managing critical events, such as

serious haemorrhage. For invasive procedures, such as procedural sedation, there were check

sheets to support doctors in following local safety standards.

For patients nearing the end of their life, the trust used deteriorating patient plans, which

included ‘Do Not Attempt Cardio-Pulmonary Resuscitation’ (DNACPR) instructions. We saw

these completed for appropriate patients and they were brightly coloured, so they stood out

amongst the patient’s notes.


Key components of the ED Safety Checklist have progressively improved over the past 12

months. Compliance with NEWS recording and completion of the safety checklist was audited

monthly. In the four months prior to the inspection, the department had scored between 94-97%

for the completion of a NEWS score at initial assessment (within target) but only 60-69% for

ongoing hourly NEWS assessment (below target). The ED Safety Checklist had been an area of

continued focus by the operational team and the Board. Monthly compliance was reported to both

the Board and the Quality and Performance Committee through the Quality and Performance

Report. As a result of this further improvement had been seen over the past three months to

90% (better than target).

Panic alarms were distributed to staff, who wore them around their necks. Reception staff

were wearing their alarms but had had no drills or training on the action to take should they hear

the alarms sounded elsewhere in the building. There was a panel located in reception which

identified where the alarm was being sounded within the department.

Staff felt there was insufficient cubicle space led to delays in physically assessing patients.

Senior medical staff told us their most significant concern was for the undifferentiated patients

waiting in the corridor. This meant that, although they had their clinical observations monitored by

healthcare assistants to identify signs of clinical deterioration, doctors had not yet diagnosed their

illness and therefore did not know how urgent their medical needs were or to which team they

should be referred.

The senior nurse and senior consultant were one of the tools available to the department

to help the senior team coordinate services. This would allow joint decisions to be made

about clinical priority and progression of care.


We had concerns about the safety and security arrangements for people suffering from

mental health illness. Whilst risk assessments took place to ascertain the risks to the patient and

others while people were in the department, we observed one occasion when the advice had not

been followed. On this occasion, one to one supervision had been recommended and had initially

been provided, but the supervision had ended at the discretion of a non-clinical member of staff.

One of the inspection team alerted a member of staff and supervision was arranged, however staff

and the public had been at risk during this time.


The emergency department ensured patients received diagnostic tests soon after their arrival.

The department managed the risks of patients waiting to commence treatment effectively.

Panic alarms had been provided to the reception staff. These were worn on lanyards. The

receptionist on duty at the time of our visit was not wearing their panic alarm. They reported that it

had been placed in their in-tray during a period of leave. There had been no training or instruction

on their use or how to respond in an emergency if another member of staff had pressed theirs for

assistance. The staff were familiar with the sound of the alarm as they were often set off in error.

Individual patient risk assessments were carried out for infections, falls, pressure ulcers and

property. Where risk assessments were completed, the action taken was documented on the form.

Staff monitored patients while in the emergency departments to assess their risk of deterioration.

They used the national early warning score (NEWS) on arrival and throughout the patient’s stay in

the department. Compliance with NEWS was audited monthly. In the last four months the

department had scored between 93 and 100% for completion of NEWS at initial assessment

(within target of 80%) and 80-87% compliance for ongoing hourly assessment (within target of

80%).

There were only two resuscitation bays in Cheltenham General Hospitals’ emergency

department, which filled quickly when Gloucestershire Royal Hospital diverted ambulance

patients to them. Staff would move patients around the department to accommodate those

needing a resuscitation bed.

The senior nurse and the senior consultant jointly completed hourly board rounds. This allowed

joint decisions to be made about clinical priority and progression of care.

The trust scored about the same as other trusts for all the five Emergency Department Survey

questions relevant to safety.

Questions are scored on a scale from 0 to 10, with 10 being the most positive.

Question Score RAG

Q5. Once you arrived at the hospital, how long

did you wait with the ambulance crew before

your care was handed over to the emergency

department staff?

8.7 About the same as other

trusts

Q8. How long did you wait before you first spoke to a nurse or doctor?

7.1 About the same as other trusts

Q9. Sometimes, people will first talk to a nurse or doctor and be examined later. From the time you arrived, how long did you wait before being examined by a doctor or nurse?


Q33. In your opinion, how clean was the emergency department?



Q34. While you were in the emergency department, did you feel threatened by other patients or visitors?


(Source: Emergency Department Survey (October 2016 to March 2017; published October 2017)

Nurse staffing

Staffing levels and skill mix was planned and regularly reviewed so people received safe

care and treatment and staff did not work excessive hours. Nurse staffing levels and skill mix

had been assessed, using national guidance and acuity tools, alongside departmental information.

The last review had taken place in August 2018, but the results had not yet been published.

Nurse vacancies were high across both sites, but the substantive fill rate had been steadily

improving over the last six months. There was ongoing recruitment of nurses and the ability to

recruit and retain sufficient staff. Those responsible for nurse rotas were assured that the

department was safe by using a staffing tool which monitored department safety. A warning was

created when risks were present, such as excessive agency staff on a specific shift. Staffing had

been identified by management as a concern and was on the emergency department risk register,

classed as a high risk (score of 9).

During our last inspection, nurse vacancies were at 14.7% and this had improved to 10.8%

during this inspection. The trust did not have an overall target for vacancies. Recent actions to

improve staffing had been to introduce two new roles: band 7 nurse co-ordinators, and band 7

physician’s assistants. The department was still recruiting nurse co-ordinators so there was

sometimes no co-ordinator during the night, but the intention was for there to be a co-ordinator 24

hour a day.

During shift changes, nurses completed bedside handovers with the nurse taking over their

patients. The departments did not have joint scheduled handover meetings, including nursing and

medical staff, in line with recommendations of the Royal College of Emergency Medicine

Standards for Emergency Department Care (2017).


Nurse staffing levels were maintained to provide one nurse to every three or four patients

in majors and this level was maintained for the duration of our inspection. This had been

developed in line with recommendations from the Royal College of Nursing. Levels were

maintained using a combination of employed and agency staff. The nurse in charge was able to

review staffing throughout the day and was able to pull extra resource should demand or acuity

increase.

The exception was for patients queuing in the corridor. At all times there was a nurse and a

healthcare assistant allocated to look after patients queuing in the corridor.

Each corridor had registered nurses and/or healthcare assistants assigned. The department

had two corridor spaces, the first known as the ‘ambulance corridor’ (where patients arriving via

ambulance await their handover and initial assessment), and the second corridor known as the ‘X-

ray corridor’. Healthcare assistants worked under the direction of a registered nurse, the

ambulance corridor was located within ‘majors 1’ which always has a minimum of three registered

nurses to supervise and oversee patient care.


Although there was a nurse nearby at all times, clinical observations were taken by the

healthcare assistant and there was very little face-to-face contact with the nurse. This was

because they were also receiving handovers for patients arriving by ambulance and co-ordinating

the care for the patients in majors 2, as the nurse co-ordinator was stationed away from those

patients.

Although the department did not employ registered children’s nurses, a large number of

adult nursing staff had received additional competencies and training to ensure they were

safe to care for children. Despite multiple attempts to recruit children’s nurses, posts went

unfilled. To mitigate this, the paediatric department worked closely with the emergency

department to ensure all children received appreciate care. Unwell children, once triaged, were

referred and/ or transferred to the Paediatric Assessment Unit (PAU) for ongoing care. The PAU

was part of our urgent and emergency care pathway for children, which meant that children were

appropriately care for by registered children’s nurses.

In order to meet the needs of children, during the last year over 30% of 0-1 year olds were

initially triaged in the ED and were directed to the Paediatric Assessment Unit for onward

care and treatment. Approximately 20% of children 2–5 and 6–10 are treated within the

Paediatric Assessment Unit; the remaining children are either Priority 1 cases or had fractures

requiring assessment from an emergency medicine doctor.

The ED and GP Out of Hours service predominantly managed the care of children with

minor to moderate trauma and minor illnesses. Staff providing care are supported by medical

and nursing staff with additional training in the field of paediatrics. There was always 24/7 access

to expert advice and guidance and Emergency Nurse Practitioners were available. In the event of

a baby or child requiring immediate resuscitation a specialist paediatric / neonatal team was able

to attend ED to support the child’s care.

Sickness rates

From June 2017 to May 2018, the hospital reported a sickness rate of 4.8% for registered nursing

staff in urgent and emergency care. This was higher than the trust’s overall target sickness rate

of 3.5%

Turnover rates

From June 2017 to May 2018, the hospital reported a turnover rate of 12.3% for registered

nursing staff in urgent and emergency care. This was higher than the trust target of 11%.

Support staff

At our last inspection we found there were insufficient support staff in the department.

During this inspection staff still reported there was a shortage of porters, even though the

trust had taken several actions to improve cover. Generally, there was one porter who worked

from 9am to 5pm and a second from 2pm to 10pm. However, on the first day of our inspection

there was only one porter working from 9am to 5pm. They were unclear as to why the late porter

was not working but had contacted the porter team. No further assistance was provided; therefore,

the assistant general manager and nursing staff were transferring patients to wards. At that time

there were five patients ready to be transferred to wards, with patients queuing in the corridor to

be allocated a bed. The trust had also introduced a new transfer team, which consisted of two

health care assistants, who also transferred patients. This resource was shared with radiology.

Staff told us that any delays were generally after 5pm, when there was only one porter on duty in

the department. The concern had been raised at departmental meetings and capacity within the

transfer teams was being reviewed as part of the unscheduled care winter action plan. Staff


followed criteria that if a patient had a national early warning score (NEWS) of under 4, a non-

qualified member of staff could transport them. A patient with a NEWS score over 4 would require

a registered nurse to escort the patient, which impacted on the department at busy times.


Nurse staffing levels were maintained to provide one nurse to every three or four patients

and this was maintained for the duration of our inspection. However, the department suffered

high staff turnover rates and, to maintain minimum safe staffing levels, a high number of agency

staff were used. During our last inspection, nurse vacancies were at 11.2% and this had increased

to 20.4% as of May 2018. The hospital had recently recruited band 7 nurse co-ordinators and they

continued with their efforts to recruit and train nursing staff. The department did not employ

paediatric nursing staff as there was no children’s emergency department. Children with minor

injuries were cared for by nurse practitioners (or equivalent allied professionals) when the

department operated as a minor injuries unit. Staff had competencies in the care of children, as

described above.

Sickness rates

From June 2017 to May 2018, the hospital reported a sickness rate of 4% for registered nursing

staff in urgent and emergency care. This was higher than the trust’s overall target sickness rate

of 3.5%

Turnover rates

From June 2017 to May 2018, the hospital reported a turnover rate of 21.3% for registered

nursing staff in urgent and emergency care. This was higher than the trust target of 11%.

Both sites - bank and agency staff usage

The trust did not provide total shifts including substantive staff, so we are unable to provide a

percentage usage for bank and agency however a breakdown of total shifts from July 2017 to

June 2018 for urgent and emergency care is shown below:

Location Bank shifts Agency shifts Unfilled shifts

Gloucestershire Royal Hospital 2,486 2,335 658

Cheltenham General hospital 1,630 908 453

The number of agency nursing hours used in the ED has reduced by over 70% in the last 6

months. This was as a result of continued strong recruitment and developing incentives to support

our own bank workers.

There were assurance processes in place to ensure the quality of the bank worker. When

agency staff started in the department, they completed an induction sheet, which was signed by

the senior nurse to confirm that the temporary staff had essential knowledge to work safely. Bank

and agency staff were booked in a way which ensured that skill mix and quality of worker were

considered.

Medical staffing

Medical staff worked across both sites and emergency patients had access to a consultant

seven days a week. At Gloucestershire consultant cover was from 8am to midnight and at


Cheltenham General Hospital it was from 8am to 10pm on week days and from 9am until 6pm at

weekends,

As of May 2018, the proportion of consultant staff reported to be working at the trust was

higher than the England average. There were 20 whole time equivalent consultant positions in

total, including one vacancy, but at the time of the inspection, there were three consultants on

long-term absence. There was also a continuing shortage of middle grade doctors. Long-term

locum staff were used where possible to ensure they were familiar with the clinical protocols and

information systems. There was active recruitment ongoing for these posts at the time of the

inspection.

There were proportionally more junior (foundation year 1-2) and consultant level staff than

the England average, but fewer in the registrar group.

Staffing skill mix for the 36 whole time equivalent staff working in urgent and emergency care at Gloucestershire Hospitals NHS Foundation Trust. This

Trust England average

Consultant 46% 29% Middle career^ 11% 15% Registrar group~ 16% 33% Junior* 27% 23%

^ Middle Career = At least 3 years at SHO or a higher grade within their chosen specialty ~ Registrar Group = Specialist Registrar (StR) 1-6 * Junior = Foundation Year 1-2

(Source: NHS Digital Workforce Statistics)

All medical staff, except for F1 level (Foundation year one doctors), worked across both

emergency departments. F1 doctors were allocated to a specific hospital to provide greater

stability and allow continuity with their training and supervision.

As of May 2018, the trust reported a vacancy rate of 19.8% for medical staff in urgent and

emergency care. Most vacancies were in the middle grade doctor group, with 10 whole-time

equivalent posts and only 6.4 filled. Vacant shifts were filled by acting-down consultants and

locum staff, so impact on patient safety was minimised. The trust recognised that using

consultants to fill the vacant posts was costly, there was a substantial positive impact on safety of

care.

However, we raised concerns at our last inspection about the sustainability of this

arrangement. The clinical lead reported the middle grade vacancies were mostly due to common

employment instabilities in that group of staff (for example, people accepted middle grade posts

often as an interim between training and career development stages). From June 2017 to May

2018, the trust reported a turnover rate of 10.2% for medical staff in urgent and emergency care.


This was lower than the trust target of 11%. Sickness rates were also very low in the medical

staff group, just 1.5% against a trust target of 3.5%.

Bank and locum staff usage

The high use and cost of agency medical staff was recorded on the emergency

department risk register as a high risk. New, locum and agency staff were given a local

induction and initially worked alongside a substantive doctor, who ensured they were familiar

with the information systems and clinical pathways.

Most locum shifts were filled by internal positions, were long term locums, or had

previously trained at the trust. This meant that they were familiar with departmental

processes. Additionally, locum staff benefitted from the trust appraisal system.

The trust did not provide total shifts including substantive staff, so we are unable to provide a

percentage usage for locum and agency however a breakdown of total shifts from July 2017 to

June 2018 for urgent and emergency care is shown below.

The breakdown by site is shown in the table below.

Location Locum shifts Agency shifts Unfilled shifts

Doctors in training 696 892 1

Middle grades 702 322 0

(Source: Routine Provider Information Request (RPIR) - Medical agency locum tab)

There were effective medical staff handover arrangements, which ensured safe continuous

care for patients. There were four verbal handovers during the day to accommodate the varying

shifts. The 4pm handover was an extended handover, to which the advanced nurse practitioner

and physician’s assistants were invited, however the nurse co-ordinator was not. The handover

included information about the department, bed availability, complex patients and sometimes

included discussion of incidents and complaints.

The emergency department did not see sufficient children to require a paediatrician,

however there were three consultants in the department with additional training in

paediatric emergency care and there was a designated clinical lead for children. At least

one member of staff was available each shift who was trained in paediatric life support.

Records

Staff mostly kept detailed records of patients’ care and treatment and records were legible

and stored securely. There were both paper and electronic records and staff knew where to find

the information they needed, and all records were stored confidentially. Records were secure; staff

could access the computer record system with a password. We observed staff logging out of

computers when they were not in use to ensure patient records were protected, however all

computers automatically locked if they were left unused. Paper records were stored securely

within clinical areas and away from the public and were quickly scanned onto the system after the

patient was discharged.


A new IT record keeping system had recently been introduced trust-wide that had caused

problems elsewhere in the trust, however there were no obvious signs of disruption in the

emergency department. Most nursing and medical records were still completed on paper. Once

scanned, the notes could be viewed by others on the computer system.

The standard of contemporaneous record keeping within these was high. We reviewed 20

sets of patient records during our inspection across both sites. Writing was legible and written

notes were detailed. On the whole, nursing records were up to date and the hourly checklists were

completed, including patient observations. However, internal compliance audits showed that

completion of the hourly checklist was not always consistent. Over the six months prior to the

inspection, the completion rate was between 82% and 90% at Cheltenham General Hospital and

between 73% and 85% at Gloucestershire Royal Hospital.

During our review of patient records, there were two sections of the documentation that

were not always completed, the safeguarding risk assessment and the patient handover

sheet. We found the same omissions at both emergency departments. The handover section was

a new addition to the form and staff were getting accustomed to completing it. The section had

been added to improve the quality and safety of patient handovers, by summarising key

information on a single page. It was relevant only for patients due to be admitted. There was

confusion over whether the safeguarding risk assessments required completion on every

occasion. Two nursing leads were asked about the completion of these risk assessments, one

confirmed that it should be completed, and another understood it did not need to be. The medical

lead advised that clinical judgement could be applied. During the inspection a safeguarding

referral was overlooked for a vulnerable adult who did not have a risk assessment completed,

therefore we were not assured that documentation was recording risks accurately.

We also reviewed the documentation for patients who had received a mental health

assessment. These records were comprehensive and clear to read; however, they were not

available on the hospital’s system for nursing and medical staff to review during the same episode

of care. Detailed records were recorded on the mental health trust’s electronic system and a

detailed summary with a risk management plan were later submitted and attached to emergency

departments notes. This impacted sometimes of the smooth transition of patients between the

services.

Medicines

The service did not always follow best practice when recording and storing medicines. However, patients received the right medication at the right dose at the right time. Medicines at both hospitals were appropriately prescribed and administered to people in line with the relevant legislation, current national guidance or best available evidence. The trust’s medicines policy was accessible on the trust’s intranet, which included prescribing guidelines. Staff had access to hard copies and online BNF (British National Formulary) for medicine information. After a year of working for the trust, nurses could administer some medicines in line with patient group directions. These are written instructions allowing registered health care professionals to administer certain medicines to pre-defined groups of patients without a prescription. Some nurse practitioners were undertaking prescribing courses and most advanced nurse practitioners could prescribe medicines.

There were local microbiology protocols for the administration of antibiotics. These were

reviewed periodically in line with trust’s antibiotic stewardship policy. We saw evidence of

compliance with antibiotic stewardship guidelines. For example, one patient we observed was


referred back to their GP as they had attended requesting antibiotics for a chronic ongoing

condition. Staff helped make an urgent appointment and speak with their GP on their behalf.

Patients were given advice about their medication. Staff at both hospitals explained to patients

why they were receiving certain medicines. Pre-labelled TTAs (medicines given to a patient ‘to

take away’ when discharged) were given to patients when appropriate and staff could explain to

patients what they were for how they should be taken.

The service made sure that people received their medicines as intended and recorded them

appropriately. Medicines were regularly audited, and incidents and errors were recorded on the

adverse incident system. We were given an example of how changes had been made to their

practice following a recent incident.


Medicines and medicines-related stationery were not always managed safely and securely.

We found some discrepancies in the controlled drug register, in that all entries had not been

completed in full. The records did not always record the dose administered, the patient’s name or

the signature of the person carrying out the administration. Daily checks had been completed but

had not picked up these issues.

Medicines were stored securely in locked cabinets and fridges within locked clinical

treatment rooms. Controlled drugs balance checks were completed in accordance with the trust

policy by two nurses. Random balance checks were also completed, and physical stock matched

the controlled drug registers. Medicines were only accessible by clinical staff and drug keys were

usually kept secure, except for one occasion when we observed the keys to the medicine cabinet

left on the desk at the nurses’ station, unattended for four minutes.

Prescription pads in the major’s area were kept securely but were left out in minor’s area.

During our inspection we observed three pads out on the nurses’ station in minors which posed

the risk medicines of being inappropriately obtained by members or staff or the public.

We found some medicines in the department were out of date. We found date-expired fluids in

the cupboard store, where new stock had been put on top of old, and date expired-injections were

found in the medicines cupboard in the resuscitation area. In minors we found date-expired

medicines on top of the “eye trolley” and also within the medicines trolley. In addition, oxygen

cylinders were not always stored securely, sometimes being left loose on the floor, where they

could fall over and injure someone.

Medicines storage room temperatures were routinely monitored and maintained within expected

levels.


The arrangements for managing medicines and medicines-related stationery were safe

most of the time. Medicines were stored securely in locked cabinets and fridges within locked

clinical treatment rooms. They were only accessible by clinical staff and keys were kept by a

member of staff. Controlled drugs balance checks were completed in accordance with the trust

policy by two nurses. Random balance checks were completed, and physical stock matched the

controlled drugs register. Arrangements were also in place to safely store and monitor the use of

prescription forms.

However, medical gases, including nitrous oxide and oxygen, were stored in the cleaning

room. They were loose on the floor, rather than in racking, which meant there was a risk they


could fall over and cause injury. The door was left open, so they were not secure, and vulnerable

to theft and misuse. When stored on patient trolleys, cylinders were chained to the trolley to

prevent them from falling. In the cleaning room there was no signage to inform staff and visitors of

their presence and the safety procedures to be observed. There was a guideline for the use of

nitrous oxide, but this was out of date.

Medicines storage room temperatures were constantly monitored but staff did not always

act when temperatures were out of range. The medicines fridge had a maximum temperature

recorded of 14.6 C for each day from 1 October to 10 October, which was outside of the safe

range, but no action was recorded. When we raised this raised with staff they were not able to

reset the fridge display. When the instructions were found, a reset was performed, and action was

then taken to make the information about carrying out a reset available to all staff.

Incidents

The service managed safety incidents well. There were appropriate systems and processes

which supported staff to report incidents and the service acted to investigate and learn from

incidents. Staff in the emergency departments understood their responsibilities to raise concerns

and to report safety incidents, concerns and near misses.

We reviewed the incidents reported in the emergency departments and these included a

range of issues, including challenges to service delivery, equipment issues and delays in

care or treatment. The incident reporting system was electronic and available on the trust’s

intranet system. Some staff reported they found it time-consuming to complete adverse incident

reports, particularly when having to decide the categories the incident belonged to. They said this

sometimes deterred them from completing the forms when the department was very busy.

Trust systems ensured that when incidents were reported, they were reviewed by a

‘scoping panel’ to establish whether the incident had resulted in harm and whether it met

the threshold of a notifiable incident. There was a nominated consultant lead in the department

who was responsible for co-ordinating the investigation of serious incidents. All serious incidents

were reviewed at a quality board. The trust ensured cases brought to their attention through claims

and inquests were reviewed to ensure duty of candour principles were applied and a full

investigation was undertaken.

Incidents were also reviewed as part of the mortality and morbidity review process. All

patient deaths were reviewed using a structured judgement review (SJR) methodology. This

looked at all stages of the patient’s care and determined whether care and treatment had been

optimal and in line with guidance. These reviews were completed by all medical staff once they

had received training in SJR. Learning from patient deaths had been identified as a key priority for

the trust and learning was identified, even when the shortcomings in care had not contributed to

the patient’s death. Learning was cascaded to medical and nursing staff to ensure that learning

was gained across all professions.

Learning from incidents was encouraged and, where errors in care were identified, these

were handled in a supportive way, that encouraged learning and improvement. Staff

received feedback about the incidents they reported, and learning was discussed in monthly staff

meetings, clinical governance and mortality and morbidity meetings. Minutes from these meetings

were shared with all staff and the meetings were multi-disciplinary. Learning was also shared

through a six-monthly newsletter.


Staff had a good understanding of the duty of candour. Regulation 20 of the Health and Social

Care Act 2008 (Regulated Activities) Regulations 2014 was introduced in November 2014. This

regulation requires a provider to be open and transparent with a patient or other relevant person

when things go wrong in relation to their care and the patient suffers harm or could suffer harm,

which falls into defined thresholds. Staff were able to explain when the duty was applicable and

how they would ensure it was applied and recorded. Medical staff told us they also provided pro-

active apologies to patients who may not have suffered significant harm but nevertheless

experienced errors in their care. Medical staff routinely completed reflections on their care when

learning was identified.

Never Events From August 2017 to July 2018, the trust reported no incidents classified as never events for urgent and emergency care. Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event. (Source: NHS Improvement - STEIS) Breakdown of serious incidents reported to STEIS In accordance with the Serious Incident Framework 2015, the trust reported four serious incidents (SIs) in urgent and emergency care which met the reporting criteria set by NHS England from August 2017 to July 2018. They were:

Maternity/Obstetric incident meeting SI criteria: mother and baby (this include foetus, neonate and infant)

Diagnostic incident including delay meeting SI criteria (including failure to act on test results)

Unauthorised absence meeting SI criteria Abuse/alleged abuse of child patient by third party

(Source: NHS Improvement - STEIS (01/08/2017 - 31/07/2018)

Detailed investigations were completed for all serious incidents. The department

endeavoured to learn from things that had gone wrong to ensure the same thing did not happen

again.

Safety thermometer

There were effective tools for the monitoring of overall safety in the department. The

Safety Thermometer is often used in hospitals to record the prevalence of patient harms and to

provide immediate information and analysis for frontline teams to monitor their performance in

delivering harm free care. Measurement at the frontline is intended to focus attention on patient

harms and their elimination.

The emergency departments did not use the safety thermometer, but instead used nursing

metrics and a performance dashboard to measure quality in the department. The metrics

included falls, drug errors, adverse incidents and NEWS audits and were shared at weekly staff

meetings and posted on the intranet.


Is the service effective?

Evidence-based care and treatment

The emergency departments followed guidance from NICE (National Institute for Health and

Care Excellence), the ‘Clinical Standards for Emergency Departments’ produced by the

Royal College of Emergency Medicine and guidance from other expert and professional

bodies. Guidelines were available on the intranet and could be viewed by all staff working in the

department, including locum and agency staff. They were reviewed and updated regularly by a

nominated member of medical staff. Some important guidelines about critically unwell patients

were displayed on the wall and available in folders in the majors and resuscitation departments.

Proformas were used for conditions such as stroke and sepsis to support staff in delivery high

quality care.

Guidelines were used in the management of sepsis were based on the ‘Sepsis 6’ pathway.

Separate guidance and tools were used for children of different age groups. Screening took place

on all patients based on the ‘National Early Warning Score’ which is a monitoring tool used to

identify how unwell a patient is based on physiological measurements. The new clinical lead had

reviewed the sepsis guidance in the trust.

There were clinical pathways for the management of patients with stroke and chest pain

and checklists were used to ensure invasive procedures were performed safely. Children

were referred to regional specialist units for conditions such as burns and trauma.

There was a programme of quality improvement and clinical audit led by two consultants.

This ensured that clinical care that was not in line with best practice guidance was identified and

improved where necessary. The trust participated in relevant national benchmarking clinical audits

led by the Royal College of Emergency Medicine. The service also participated in national trials,

such as ‘NoPac’ which looks at the use of tranexamic acid in the treatment of epistaxis (nose

bleeds) and ‘Revert’ which tests a modified manoeuvre to resolve a type of abnormal heart

rhythm.

Regular mortality and morbidity meetings took place in which patient care was

retrospectively reviewed. This was completed through a process of structured judgement review

in which all medical staff were trained. This is a method endorsed by the Royal College of

Physicians. We reviewed several of the department’s mortality reviews and saw that appropriate

actions were identified, and staff were supported to improve on occasions when quality of care

was a concern. Regular mortality and morbidity newsletters were sent to staff, with reminders

about treatment guidelines that had not been followed in the cases reviewed.

Care and treatment decisions were non-judgmental and did not discriminate against people

from protected or marginalised groups. We observed high quality, evidence-based care

provided by staff to a wide range of patient groups, with consideration given to the holistic needs

of those who were vulnerable, including patients living with dementia and learning disabilities.

Audits showed that care and treatment provided was provided in line with best practice and

evidence-based guidance. For example, the department met the European Society of Cardiology

(ESC) guidance for the management of acute ST elevation MI on arrival with 60% being scanned

in a timely way which represents good performance. The National Institute of Health and Care

Excellence recommend that 50% patients suspected of having a stroke should receive a CT scan

within one hour. The trust were ensuring that 60% of patients received their scan in a timely way

which showed effective care being provided.



There was close interaction with a locally commissioned provider that provided

management advice and transport for critically ill children. As part of their service, they

provided up to date paediatric guidelines about the care of critically unwell children and

individualised drug sheets for common medicines. There was a large display board next to the

resuscitation bay used for children so that staff could quickly see relevant guidance.


During our inspection we found on the wall of the resuscitation area a ‘management of the

febrile child’ guidance document from 2012. New guidance was published about management

of the febrile child in 2017. Although we did not check whether there was up to date guidance on

the intranet, we were satisfied that there was an effective system for the regular review of trust

guidance on the intranet.

Patients with strokes and orthopaedic trauma were taken to a nearby hospital.

Nutrition and hydration

Staff gave patients enough food and drink to meet their needs. Patients had their nutrition and

hydration needs considered and were offered food, drink or administered fluids when they were

needed. Staff provided food and hot and cold drinks to patients who were spending a length of

time in the emergency department.

There were vending machines in the waiting areas and catering outlets were located in both

main hospitals, where hot food could be purchased. There were signs displayed asking

patients to refrain from eating and drinking until they had been assessed. Fluid charts were used

to monitor the fluid intake of children and rehydration powders were used for children who were

dehydrated.

Emergency Department Survey 2016

In the CQC Emergency Department Survey, the trust scored 6.6 out of 10 for the question “Were

you able to get suitable food or drinks when you were in the emergency department?” This was

the same as other trusts.



A hot drinks trolley had been recently introduced in the emergency department where

nurses could get hot drinks for patients. We did not see many occasions when patients were

provided with drinks during our inspection; however, the patient safety checklist prompted staff to

offer refreshments to patients every two hours and we observed staff asking patients if they

wanted a drink. Patients we spoke with confirmed they had been offered a drink.

Children were encouraged to drink and those at risk of dehydration had their fluid levels monitored

during their stay in the emergency department.


Hot soup and bread were available for patients who had been waiting in the department for

a length of time. In the children’s department there was a hydration station where parents could

obtain water for children to drink.


Hot meals could be ordered from the main hospital kitchens for patients who had been in

the department for a length of time. There were vending machines in the waiting area and a

water dispenser in the corridor for staff and patients to help themselves.

Pain relief

Staff asked patients whether they were in pain and offered pain relief when they were

triaged soon after their arrival in the emergency department. When self-presenting patients

arrived in the department in severe pain, we observed reception staff ensuring they were seen

straight away.

Triaging staff could provide patients with analgesia, such as paracetamol, through a

patient group direction or they could ask a doctor to prescribe pain relief. Initial pain levels

were recorded using a scoring system of ‘0’ for no pain and ‘3’ for severe pain. This was mostly

done without delay and we observed it happening on many occasions throughout our inspection.

After assessment by a doctor, individual analgesic plans were documented, and pain levels

were checked at least hourly by the nursing staff, alongside patients’ vital signs. All patients

we spoke with said they had been offered pain relief when they needed it. Audits of safety

checklists shown that the management of pain was improving month on month.

Emergency Department Survey 2016

In the CQC Emergency Department Survey, the trust scored 6.8 out of 10 for the question

“How many minutes after you requested pain relief medication did it take before you got

it?” This was the same as other trusts.

The trust scored 8.1 out of 10 for the question “Do you think the hospital staff did everything they

could to help control your pain?” This was the same as other trusts.



Staff assessed and monitored patients regularly to see if they were in pain. Whilst patients

were always offered or given analgesia, we observed some occasions when patients with

musculoskeletal injuries were not offered appropriate support from nursing staff. On one occasion

we observed a patient who had injured their ankle, and been triaged, hop across the room to pick

up a stool to support their foot. On another occasion a patient who was waiting for x-ray results for

a possible fractured wrist had no sling or pillow to support their arm and seemed uncomfortable.

Regular audits were undertaken looking at how pain was managed in the emergency

department. These showed room for improvement. In the last recorded month (September

2018) 88% of patients had their pain level assessed after arrival, 72% showed as having analgesia

offered, 69% had their pain assessed hourly and 64% had pain relief offered within acceptable

time limits.


In the children’s emergency department staff could administer ibuprofen and liquid

paracetamol for pain under a patient group direction. Staff used an aid to help them assess

the pain levels of people with communication difficulties, such as children and people living with

dementia. This was an adapted wong-baker tool comprising of faces with a selection of

expressions the patient could point to. In the case of children, there was a further tool describing

the usual behaviour expressed by infants and children suffering different levels of pain.


Staff assessed and monitored patients regularly to see if they were in pain. Regular audits

were undertaken looking at how pain was managed in the emergency department. The most

recent audit (September 2018) identified good performance. 100% of patients had their pain level

assessed after arrival, 100% showed as having analgesia offered, 85% had their pain assessed

hourly and 100% had pain relief offered within acceptable time limits.

Patient outcomes

The service monitored the effectiveness of care and treatment and used the findings to

improve them. This was achieved through a programme of national and local audit.

Within this section below there is reference to RCEM (Royal College of Emergency Medicine)

which coordinates a range of national clinical audits. Key standards have been set by RCEM to

assist emergency departments to improve the quality of their care. The standard set for many of

the clinical indicators is 100%; however, many hospitals are not yet meeting that standard.

Therefore, we have also identified how this service compares against others in the UK.

Medical staff knew how the service was performing against national standards and how

they compared with other similar services. Positive outcome results were displayed in the

department and areas for improvement were discussed in consultants’ meetings and presented

to all staff in multidisciplinary governance meetings. Audits were also discussed during middle-

grade doctor teaching sessions. There was a clear link between national audit outcomes and the

quality improvement programme. This ensured the service strived to make improvements when

the need was identified.

In most areas, the service performed in line with or better than the UK average in most of

the standards measured. There were some areas for improvement identified in the RCEM audit

of moderate to severe asthma at Gloucestershire Royal hospital at both hospitals. The trust had

identified it was an outlier in this area and had quality improvement projects in progress for each.

The national audit data available showed the following:

RCEM Audit: Moderate and acute severe asthma 2016/17 (Cheltenham General Hospital) In the 2016/17 Royal College of Emergency Medicine (RCEM) Moderate and acute severe asthma audit, the emergency department failed to meet any of the standards, but they were comparable to the England average. The department was in the upper UK quartile for one standard: Standard 5: If not already given before arrival to the emergency department, steroids should

be given as soon as possible as follows: o Adults 16 years and over: 40-50mg prednisolone PO or 100mg hydrocortisone IV o Children 6-15 years: 30-40mg prednisolone PO or 4mg/kg hydrocortisone IV o Children 2-5 years: 20mg prednisolone PO or 4mg/kg hydrocortisone IV


Standard 5b (fundamental): within 4 hours (moderate).

This department: 52.9%; UK: 28%. The department’s results for the remaining six standards were all between the upper and lower UK quartiles. (Source: Royal College of Emergency Medicine) RCEM Audit: Moderate and acute severe asthma 2016/17 (Gloucestershire Royal Hospital) In the 2016/17 Royal College of Emergency Medicine (RCEM) Moderate and acute severe asthma audit, the emergency department failed to meet any of the standards. They were comparable to the England average in five areas, but there were two areas where outcomes were poorer. The department was in the lower UK quartile for two standards: Standard 3 (fundamental): High dose nebulised β2 agonist bronchodilator should be given

within 10 minutes of arrival at the emergency department. This department: 10%; UK: 25%. Standard 9 (fundamental): Discharged patients should have oral prednisolone prescribed as

follows: o Adults 16 years and over: 40-50mg prednisolone for 5 days o Children 6-15 years: 30-40mg prednisolone for 3 days o Children 2-5 years: 20mg prednisolone for 3 days This department: 30.4%; UK: 52%.

The department’s results for the remaining five standards were all between the upper and lower UK quartiles. (Source: Royal College of Emergency Medicine) RCEM Audit: Consultant sign-off 2016/17 (Cheltenham General Hospital) In the 2016/17 Consultant sign-off audit, the emergency department failed to meet any of the standards, but they were comparable to the England average. The department was in the upper UK quartile for three standards:

Standard 2: (developmental): Consultant reviewed: fever in children under 1 year of age. This department: 60%; UK: 8%.

Standard 3: (fundamental): Consultant reviewed: patients making an unscheduled return to the emergency department with the same condition within 72 hours of discharge. This department:58.3%; UK: 12%.

Standard 4: (developmental): Consultant reviewed: abdominal pain in patients aged 70 years and over. This department: 25%; UK: 10%.

The department’s result for the remaining one standard was between the upper and lower UK quartiles. (Source: Royal College of Emergency Medicine) RCEM Audit: Consultant sign-off 2016/17 (Gloucestershire Royal Hospital)


In the 2016/17 Consultant sign-off audit, the emergency department failed to meet any of the standards, but they were comparable to the England average. The department was in the upper UK quartile for two standards:

Standard 2: (developmental): Consultant reviewed: fever in children under 1 year of age. This department: 25%; UK: 8%.

Standard 3: (fundamental): Consultant reviewed: patients making an unscheduled return to the emergency department with the same condition within 72 hours of discharge. This department: 45%; UK: 12%.

The department’s results for the remaining two standards were all between the upper and lower UK quartiles. (Source: Royal College of Emergency Medicine) RCEM Audit: Severe sepsis and septic shock 2016/17 (Cheltenham General Hospital) In the 2016/17 Severe sepsis and septic shock audit, they were comparable to the England average in six areas, but there were two areas where outcomes were poorer. The emergency department was in the lower UK quartile for two standards. Standard 2: Review by a senior (ST4+ or equivalent) emergency department medic or

involvement of critical care medic (including the outreach team or equivalent) before leaving the emergency department. This department: 35.6%; UK: 64.6%.

Standard 7: Antibiotics administered: Within one hour of arrival. This department: 20%; UK:

44.4%. The department’s results for the remaining six standards were all between the upper and lower UK quartiles. (Source: Royal College of Emergency Medicine) RCEM Audit: Severe sepsis and septic shock 2016/17 (Gloucestershire Royal Hospital) In the 2016/17 Severe sepsis and septic shock audit, they were comparable to the England average in six areas, but there was one area where outcomes were poorer. The emergency department was in the upper UK quartile for two standards. Standard 3: O2 was initiated to maintain SaO2>94% (unless there is a documented reason not

to) within one hour of arrival. This department: 63.6%; UK: 30.4%.

Standard 4: Serum lactate measured within one hour of arrival. This department: 77.8%; UK: 60%.

The department was in the lower UK quartile for one standard: Standard 7: Antibiotics administered: Within one hour of arrival. This department: 18.2%; UK:

44.4%. The department’s results for the remaining five standards were all between the upper and lower


UK quartiles. (Source: Royal College of Emergency Medicine) Since this audit was completed, the trust had developed a sepsis programme, working towards a CQuIN for sepsis (a CCG-led financial initiative – ‘commissioning for quality and innovation’). The trust now reports the patients screened for sepsis is consistently maintained between 95-100%. The patients receiving antibiotics within an hour of diagnosis is maintained between 80-90%. Additionally, the proportion of patients screened for sepsis is above 98%. Unplanned re-attendance rate within seven days From August 2017 to July 2018, the trust’s unplanned re-attendance rate to A&E within seven days was worse than the national standard of 5% and about the same as the England average. We asked department leads about the increase in reattendance over the last six months. They understood this was related to the new streaming process where a number of patients are booked in for tests at a later date, and therefore book into the emergency department when they return. Unplanned re-attendance rate within seven days - Gloucestershire Hospitals NHS Foundation Trust


Competent staff

People received care and treatment from staff with the right skills, experience and

knowledge. Many nursing, and support staff had not received a recent performance appraisal.

There was a development plan for nursing staff of all grades and this included mandatory

subjects, management subjects and clinical subjects.


There was a specific development pathway for nurse practitioners, including academic

requirements, alongside locally delivered subjects such as clinical history-taking and

patient group directions. Staff had access to other training and development opportunities,

including additional skills needed for their roles.

Medical staff told us the service supported learning. One member of medical staff, who had

joined in the last six months, described the department as “very supportive” and said they had a

“very encouraging educational supervisor”. There was regular protected training time for junior and

middle grade doctors and each training doctor was allocated their own educational supervisor.

Consultants acting as educational supervisors had volunteered for that role to ensure they were

committed. Nursing staff were asked for their suggestions for training; at the time of our inspection

there were training sessions planned for stroke care and organ donation.

Appraisal rates From July 2017 to June 2018, 62% of staff within urgent and emergency care trust-wide received a performance appraisal, compared to a trust target of 80%. However, at the time of the inspection there had been improvement in the departments position bringing it in line with the trust target of 80%. Staff group Appraisals

required (YTD) Appraisals complete (YTD)

Completion rate

Support staff 1 1 100% Medical staff 27 24 89% Registered nursing staff 184 110 60% Support to doctors and nursing staff 99 58 59%

Cheltenham General Hospital emergency department From July 2017 to June 2018, 70% of staff within urgent and emergency care at Cheltenham General Hospital received an appraisal compared to a trust target of 80%. However, at the time of the inspection there had been improvement in the departments position bringing it in line with the trust target of 80%. In the period (April 2017 to March 2018, 69% of staff had completed an appraisal. The breakdown by staff group can be seen in the table below: Staff group Appraisals

required (YTD) Appraisals complete (YTD)

Completion rate

Registered nursing staff 51 36 71%

Gloucestershire Royal Hospital emergency department From July 2017 to June 2018, 55% of staff within urgent and emergency care at Gloucestershire Royal Hospital received an appraisal compared to a trust target of 80%. However, at the time of the inspection there had been improvement in the departments position bringing it in line with the trust target of 80%. In the period April 2017 to March 2018, 65% of nurses had completed an appraisal. The breakdown by staff group can be seen in the table below: Staff group Appraisals Appraisals Completion


required (YTD) complete (YTD) rate Registered nursing staff 99 55 56%

(Source: Routine Provider Information Request (RPIR) - Appraisal tab)

Multidisciplinary working

Staff from different teams and divisions worked effectively together as a team to benefit patients.

Doctors, nurses and other healthcare professionals supported each other to provide good care.

Within the emergency departments there was good communication and effective relationships

between staff groups. There was little in the way of occupational hierarchy and staff were

comfortable being challenged. Each Tuesday morning a meeting was held to discuss the day to

day running of the department. This was a multidisciplinary meeting chaired by the matron and

attended by nursing and medical staff.

Medical staff and department leads reported significant improvements to the working relationships

with the rest of the acute medical team in unscheduled care since our last inspection. They felt

they worked as a more cohesive team and there was a noticeably improved sense of collective

responsibility when the emergency department was crowded. This was less so for other

specialties, such as surgery and orthopaedics. However, senior leaders reported there had been

some improvement since the last inspection and relationships were still positive.

When patients, referred by their GP to a speciality team, arrived in the department the team were

bleeped. There were professional standards which required specialty doctors to respond to bleeps

within 30 minutes and to review patients in the emergency department within 60 minutes of

referral. Staff told us there were sometimes significant delays, which caused waiting time

standards to be breached. However, the trust did not measure or report performance against

these standards. Friction was caused by the informal expectation that the emergency department

would assess, investigate and make decisions for patients referred by their GP to the surgical

team. We were told about some difficult phone calls between doctors from the emergency

departments and the specialty teams at both hospitals, which had taken time and caused

frustration. We discussed this with the clinical lead, who assured us that these admission

pathways were being reviewed, but progress in this area had been slower.

For patients with mental health concerns, care was mostly provided in a coordinated way. There

were clear pathways for referral of patients to the mental health liaison team and staff understood

how to make referrals for patients and who to refer them to.

For patients that were elderly or frail, there were designated multidisciplinary OPAL (older people

advice and liaison) teams who attended patients in the emergency department to complete rapid

consultant-led patient reviews, supported by nurses and therapists. There were smooth referral

pathways and we observed good transition between services. In addition, the Gloucester Elderly

Emergency Care (GEEC) team were available to provide expertise to support the care of elderly

patients. These teams were valued within the department and we saw appropriate patients

referred to the teams throughout our inspection. In addition, there was representation from the

GEEC team at operational meetings that ensured the needs of frail and elderly patients were

prioritised.

Seven-day services


Gloucestershire Hospitals NHS Foundation Trust

NHS England seven-day priority standards are to ensure patients can access hospital services

seven days a week. The emergency departments met the standards for seven-day service

provision.

Patients 16 years and older had access to mental health referrals 24 hours a day, seven days a

week. The service was provided by the local mental health trust


Diagnostic services, such as computerised tomography (CT), X-ray scanning, and pathology were

available seven-days a week. Patients suffering from a ST-elevated myocardial infraction (heart

attack, known as a ‘STEMI’) were transferred directly to the primary percutaneous coronary

intervention (PPCI) at Cheltenham General Hospital or a nearby specialist hospital.


Diagnostic services, such as computerised tomography (CT), x-ray scanning, and pathology were

available seven-days a week. Patients suffering from a STEMI were sent directly to primary

percutaneous coronary intervention PpPCI) suite from 8am until 6pm, five days a week. Outside of

these hours, ambulance patients were conveyed directly to a nearby specialist hospital. Self-

presenting patients were provided initial assessment and intervention and transferred by

ambulance to the specialist hospital.

Access to information


Staff mostly had access to up-to-date, accurate and comprehensive information on patients’ care

and treatment.

When people moved between teams, including at referral and discharge, information was shared

appropriately on most occasions. When patients were discharged or referred to specialty teams,

their paper records were scanned promptly so that they could be viewed by colleagues who

needed them to support ongoing care. The exception to this was the care of assessments

completed by the mental health liaison team. The mental health liaison team completed

comprehensive assessments that considered risk appropriately, but these were recorded on a

separate information recording system to the one used by the hospital trust. Handovers by the

liaison team to emergency department staff were not passed on to nurses in charge of the unit due

to only discussing with the referring clinician. This meant that staff in charge of the department

were sometimes not aware of patient’s needs and risks and lack of information could be

problematic if the patient reattended.

Staff we spoke with during our inspection confirmed that the electronic systems used to store,

manage and share information were reliable and easy to use and there were sufficient computer

stations for staff to ensure they were available when needed. Relevant protocols, policies and

guidelines were stored on the staff intranet, which was easy to navigate and could be accessed by

all staff.

Consent, Mental Capacity Act and Deprivation of Liberty Safeguards



Staff understood how and when to assess whether a patient had the capacity to make decisions

about their care. They followed trust policy and procedures when a patient could not give consent.

Staff at both hospitals introduced themselves to patients by name, explained their role and what

they were doing. During patient assessments staff spoke clearly and simply and checked that the

patient understood what they were being told. Staff obtained verbal consent prior to delivering

care.

For patients who did not have the capacity to make decisions about their care and treatment, care

was provided in patients’ best interests and with the involvement of carers and relatives. We

observed a patient living with dementia who required admission. However, once settled in the

emergency department their family did not wish them to go to the ward due to the potential

distress this may have caused. The emergency department nursing staff liaised and worked with

the medical registrar. The patient’s care and diagnostic tests took place in the emergency

department until they were satisfied the patient was well enough to be taken home.

The trust used ‘do not attempt cardiopulmonary resuscitation ‘documentation when appropriate to

record the wishes of patients nearing the end of their life. The form included details about the

patient’s thoughts on treatment as well as resuscitation, so doctors understood to what extent the

patient wanted doctors to allow a natural death if they did not have the ability to express their

wishes at the time.

Mental Capacity Act and Deprivation of Liberty training completion

The trust reported that from July 2017 to June 2018 Mental Capacity Act (MCA) training was completed by 87% of staff in urgent and emergency care, compared to the trust target of 90%. The breakdown by site was as follows: Cheltenham General emergency department: 91% Gloucestershire Royal emergency department: 85% Doctors completed training in the Mental Capacity Act through e-learning during induction. The trust did not provide data for a Deprivation of Liberty Safeguards training module. (Source: Routine Provider Information Request (RPIR) – Statutory and Mandatory Training tab)

Is the service caring?

Compassionate care

Staff showed an encouraging, sensitive and supportive attitude to people who use services

and those close to them. However, we observed some nurses were task-orientated and did not

always take the time to engage in conversation with patients.

Whilst they were sometimes waiting a long time for the next stage of their care, patients

could get the attention of a nurse when they needed to. They were well-informed about their

treatment and what the next stage of their care was.

Staff respected the personal, cultural, social and religious needs of people. We observed 10

episodes of patient care and spoke with 15 patients and carers. They were sensitive and non-

judgemental to those with complex needs, such as learning disabilities and mental health

problems. Most patients we spoke with described a positive experience of the care provided to

them and said the staff were caring. There were, however, occasions during the inspection when

the interactions between staff and patients were not as good as they could have been.


Friends and family test performance The trust’s urgent and emergency care friends and family test performance (percentage recommended) was about the same as the England average from July 2017 to June 2018. A&E Friends and family test performance - Gloucestershire Hospitals NHS Foundation Trust

(Source: NHS England Friends and Family Test)


Almost all staff provided compassionate care to patients. When staff spoke with patients and

those close to them, it was in a respectful and considerate way. Staff introduced themselves by

name, usually explained what they were doing and were kind in their manner. This was also

reflected in the comments made by patients in the friends and family questionnaire, which mostly

commented on kind and caring staff. One patient told us they “couldn’t have asked for better care”.

From April 2017 to March 2018 Gloucestershire Royal Hospital received 950 compliments.

Comments included: “staff could not be more caring or considerate”, “(doctor’s) manner was

professional, respectful, and he kept me well informed about what he was going to do” and “great

care when treated, and a friendly smile”.

Staff responded in a compassionate, timely and appropriate way when people experienced

physical pain, discomfort or emotional distress. We saw several occasions when patients

became upset and staff responded in a sensitive and caring manner. We were told of an example

where staff had spent longer than usual trying to arrange transport for a patient who said they had

no money for a taxi and their family was away. They eventually managed to find help through a

volunteer organisation.

Not all behaviours displayed in the department showed compassion towards patients. Due

to the pace of work in the department, one patient commented that staff did not always have time

to spend with them. One relative commented that nursing staff sometimes completed tasks, such

as observations, without talking to them. We observed two occasions when groups of staff

gathered in public-facing areas, such as reception, to talk about personal matters and socialise. It

was not evident to waiting patients whether staff had finished their shift and it would be likely to

cause frustration during busy times. We also saw a few occasions when nursing staff did not


respond in a supportive way to patients who were frustrated or agitated. Nursing staff tended to

stand back from these patients whilst medical staff stepped in to offer reassurance and establish

what the patient needed.

Whilst staff ensured patients were comfortable and warm whilst waiting for and receiving

treatment, they did not always make sure their privacy and dignity needs were understood

and respected. This included during physical or intimate care and examinations. We observed a

few occasions when patient curtains were not fully drawn during patient assessments or, when

they were drawn, staff would enter the cubicle without checking whether it was appropriate. An

example was an elderly and frail patient who had been given a bottle to provide a urine specimen.

Staff offered no assistance, which left the patient’s family members assisting the patient to using

the bottle. Staff did not ask the patient whether they felt comfortable with this. Two members of

staff entered the cubicle on separate occasions while the patient was exposed and using the

bottle, and on one of these occasions the curtain was left partly open. Another example involved a

patient in the resuscitation area who was using a bottle. There were no screens pulled across,

meaning the patient was in view of staff in the resuscitation area. There were other instances of

curtains not being fully closed during examinations as we walked through the department. We also

noted that waiting patients in majors two could sometimes observe care and treatment being

provided to patients in cubicles.

Patients arriving by ambulance often waited in the corridor area on chairs and trolleys

where they stayed until a cubicle could be found, or they were retrieved by the acute

medical physicians. These patients were mostly ambulatory and therefore low risk. We saw

doctors consulting with patients in the corridor, where conversations about a patient’s condition

could sometimes be overheard and clinical observations were carried out in full view of other

patients and visitors. Patients were sometimes transferred from the ambulance trolleys in the

corridor in view of waiting patients. Whilst the care of patients in the corridor was not unsafe, it was

not a positive patient experience.


Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Staff interacted with patients, their carers and relatives in a compassionate and respectful

way and were given information about their condition. We did not observe the care of patients

who were emotionally distressed or agitated during the inspection, but we spoke with patients who

reported excellent care and attention during their visit and had no complaints. One patient was

returning to give a thank you card and biscuits to the staff.

There were assessment rooms with doors used for intimate examinations and curtains

were pulled across during patient assessments. Our only negative observation was the

number of times patient assessments were interrupted during triage. Other staff kept coming in

and out of the triage room. One came in for tablets (paracetamol was kept in drug cupboard in

triage room), one came in for gloves and apron, one came in to get a form. All apologised to the

patient. However, it was potentially frustrating for the patients, including those who may have been

having sensitive or difficult conversations.

From April 2017 to March 2018 the emergency department received 16 compliments.

Comments included: “All staff were helpful and courteous and in particular I would like to praise

the triage nurse who was constantly cheerful” and “The staff looking after my husband were so

kind, they let us know who they were, kept us informed, and treated him with such respect”.


Emotional support

On most occasions support and information was provided to patients and those close to

them, including carers and family members. Medical assessments at both hospitals were

unrushed and staff took extra time to allow patients with cognitive impairment to understand and

cooperate with their examinations. An example of this was a stroke assessment on a patient who

needed some extra time to understand what a doctor was asking them to do during a neurological

assessment. The doctor was patient and took time between each test, so as not to overburden the

patient. Medical staff addressed emotional and social needs, as well as their physical ones. They

took time to explain their plans and gave patients time to ask questions. All patients we spoke with

understood what was happening and what they were waiting for.


Staff responded compassionately to patients or relatives who became upset. During our

inspection the emergency department was constantly busy and nursing care was generally

efficient and task-focused. However, there was mostly good interaction during the patient’s initial

assessment and, when patients were noticeably distressed or anxious, emotional support and

reassurance was given. We saw a patient present to the reception in a state of distress due to

severe pain. Reception staff called through to request nurse attendance. The patient was attended

to immediately by a senior nurse and taken to a private area. The patient was continually

reassured, and nursing staff stayed with the patient while they were assessed. Staff also took time

to talk to the patient in a kind and compassionate way, explaining what they were doing, what

investigations they were planning and how they would address her pain.

The departments dementia lead consultant had developed the Gloucestershire Elderly

Emergency Care Project to support patients in emotional distress. This work had been

presented to the Board and had been recognised locally in the trusts award scheme.

People who had suffered bereavement received emotional support from nursing staff. A

bereavement support team contacted relatives in the days following the death of a patient to check

on them and offer further support if needed. A local charity had donated a box to be used in the

event of sudden infant death. This included items such as teddies (one of which stays with the

infant) and clay to make hand and foot casts.


Staff provided emotional support to patients to minimise their distress. Staff responded compassionately to patients or relatives who became upset and feedback from patients was positive. The nursing staff took additional time to speak with patients and build a rapport through

conversation and humour when they were able too. We observed the care provided to a

patient who was significantly distressed and away from home. The nurse communicated with them

in a kind and sensitive way and took additional time to refer the patient to services in their home

town, where they could receive essential support from their family.

Nursing staff took time to understand the impact that illness or injury would have on

patients’ wellbeing after discharge and discussed ways of overcoming challenges they may

face. Patients who were bereaved were cared for in a quiet room away from the patient cubicles

and a member of nursing staff told us they stayed with them to provide support. We spoke with

one patient, who told us staff had “been awesome” due to the sensitive way that they had

supported them through a distressing medical emergency.


Understanding and involvement of patients and those close to them

Staff involved patients and those close to them in decisions about their care and treatment and there was particularly good engagement with those living with learning disabilities. Staff communicated with patients and explained their care, treatment and condition. We observed staff who cared for patients introducing themselves and their role and explaining what they were doing at each stage. Most patients we spoke with confirmed they knew what was happening and what the next stage of their care involved. During our inspection we observed some medical assessments of patients. Doctors in both hospitals always spoke very clearly and waited for patients to respond fully, taking extra time when there was cognitive impairment. For those with limited ability to communicate their needs, staff listened to relatives, involved them in the patient’s care and made shared decisions.

Emergency Department Survey 2016 - Gloucestershire Hospitals NHS Foundation Trust The trust scored about the same as other trusts for all 24 Emergency Department Survey questions relevant to the caring domain. Questions are scored on a scale from 0 to 10, with 10 being the most positive. Question Trust 2016 2016 RAG Q10. Were you told how long you would have to wait to be examined?


Q12. Did you have enough time to discuss your health or medical problem with the doctor or nurse?


Q13. While you were in the emergency department, did a doctor or nurse explain your condition and treatment in a way you could understand?

8.1 About the same as

other trusts

Q14. Did the doctors and nurses listen to what you had to say?


Q16. Did you have confidence and trust in the doctors and nurses examining and treating you?


Q17. Did doctors or nurses talk to each other about you as if you weren't there?


Q18. If your family or someone else close to you wanted to talk to a doctor, did they have enough opportunity to do so?


Q19. While you were in the emergency department, how much information about your condition or treatment was given to you?


other trusts

Q21. If you needed attention, were you able to get a member of medical or nursing staff to help you?


Q22. Sometimes in a hospital, a member of staff will say one thing, and another will say something quite different. Did this happen to you in the emergency department?


other trusts

Q23. Were you involved as much as you wanted to be in decisions about your care and treatment?


Q44. Overall, did you feel you were treated with respect and dignity while you were in the emergency department?


Q15. If you had any anxieties or fears about your condition or treatment, did a doctor or nurse discuss them with you?


Q24. If you were feeling distressed while you were in the emergency department, did a member of staff help to reassure you?


other trusts

Q26. Did a member of staff explain why you needed these test(s) in a way you could understand?



Question Trust 2016 2016 RAG Q27. Before you left the emergency department, did you get the results of your tests?


Q28. Did a member of staff explain the results of the tests in a way you could understand?


Q38. Did a member of staff explain the purpose of the medications you were to take at home in a way you could understand?


other trusts

Q39. Did a member of staff tell you about medication side effects to watch out for?


Q40. Did a member of staff tell you when you could resume your usual activities, such as when to go back to work or drive a car?


other trusts

Q41. Did hospital staff take your family or home situation into account when you were leaving the emergency department?


Q42. Did a member of staff tell you about what danger signals regarding your illness or treatment to watch for after you went home?


other trusts

Q43. Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left the emergency department?


other trusts

Q45. Overall... (please circle a number) 8.0 About the same as

other trusts (Source: Emergency Department Survey (October 2016 to March 2017; published October 2017)

Is the service responsive? Service delivery to meet the needs of local people


Because of pathway changes in the past 12 months there had been fewer incidents of

crowding. However, during the inspection we still found times where demand outstripped

capacity. On most days of the inspection, the department was crowded at times, and patients

waited in non-clinical areas.

Despite times of high demand, the departments managed risk well. During our inspection we

observed how the emergency departments managed crowding and the trust’s response when the

OPEL status was escalating. OPEL refers to the Operational Pressures Escalation Levels

Framework and is a standardised tool used to denote the level of pressure a hospital is under at

any time. During escalation the department followed the Emergency department escalation policy

and we saw good engagement by the wider hospital. The escalation policy outlined the actions to

be taken at each stage of escalation, with actions such as requesting support from speciality

teams to review waiting patients and communicating with patients in waiting areas about wait

times.

Although there were surges in attendances that contributed to a crowded department, it

was exacerbated by the patients waiting in the department that had been referred by

primary care services who could have been seen elsewhere. The trust was focused on

improving direct access pathways for these patients so that in future most would not need to

attend the emergency department.


There were innovative co-location processes in place throughout the unscheduled care

pathway to ensure patients were seen and treated in the most appropriate place. A

streaming nurse worked between 9:00 am and 9:15pm and was based behind the reception desk.

The nurse took phone calls when people contacted the department and gave advice about how to

access the correct care. Within the department the nurse could direct self-presenting patients to

the major’s department, wait for the triaging nurse or to see the streaming GP. The hospital was

trialling the use of a streaming GP, a project funded by the local commissioning group Monday to

Friday. The intention was for the steaming GP to assess and discharge patients with illnesses

where a medical opinion was required, such as abdominal pain. The GP also liaised with minors to

see if there were any additional patients they could see and treat. The streaming nurse could also

direct patients directly to the medical or paediatric assessment units if the GP had referred the

patient, the ward had capacity and the patient was stable with a NEWS score of 3 or below.

Patients referred by their GP for assessment by the medical team could be sent directly to the

Acute Medical Initial Assessment unit if they were clinically stable. If the NEWS score was above

three, they were assessed first in the emergency department. Similar pathways did not yet exist

for orthopaedic or surgical patients referred by their GP. Although the relevant team were

contacted, these patients were often assessed and care for by emergency staff until a member of

the speciality team could attend the department.

Crowding and use of escalation procedures


The hospital monitored the number of patients having wait in the emergency department

corridor each day. In the last six months the average ranged from 24 to 38 patients per day

at Gloucestershire Royal Hospital but had dramatically improved to six patients at the time

of the inspection. During our inspection patients rarely waited in the corridor for prolonged

periods of time. When queues developed, the department followed their escalation protocol and

we saw patients moved to the correct location for their care.

When under severe pressure the trust on occasions diverted ambulances destined for

Gloucestershire to Cheltenham Emergency Department. In the nine months from 1 January

2018 to 1 October 2018, there had been 99 diverts. This had proved an effective way of relieving

pressure in Gloucestershire Royal Emergency Department but had an immediate impact on the

department Cheltenham General Hospital. Additionally, patients who live between the two sites

would sometimes go to the quieter service, depending on clinical need, as an approach to support

the entire healthcare system.


The hospital monitored the number of patients having wait in the corridor each day. In the

last six months the average ranged from 1-2 each day at Cheltenham General Hospital and during

our inspection no patients waited in the corridor. Staff told us the department became busy quickly

when there were diverts in place at Gloucestershire Royal Hospital Emergency Department. In

response to concerns raised through the adverse incident process, the trust now ensured that

there was a discussion with the emergency team on duty at Cheltenham General Hospital before

diverts were put in place to ensure there was sufficient staffing and capacity.

When the emergency department was crowded, staff provided leaflets to patients to explain

why they were waiting. We saw ambulance patients prioritised on arrival when there was a

queue and directed for urgent intervention if it was needed. In addition to the usual site meetings,

we saw on day two of our inspection an additional meeting was held to review bed availability to


help reduce the pressures in the emergency department. Electronic information was available

during the meeting regarding the number and complexity of the patients in the emergency

department and their wait times (an escalation score was given to each patient based on their

clinical needs and presentation). There was a focus on the four and twelve hour waits to ensure

patients were admitted to the appropriate place for their care. In the six months prior to the

inspection, the number of waits in the department over 12 hours ranged from 23 per month in June

2018 and 83 per month in March 2018. Incident reporting suggested there was an increase in

pressure to move patients who were nearing the four-hour target, resulting in patients being

moved to other areas of the hospital in circumstances that were less than ideal. Examples

included patients being accommodated in a ward corridor with no allocated corridor nurse, not

having the correct equipment available and reports of aggressive or inappropriate behaviour

towards staff.

A hospital ‘safety huddle’ was held each day, attended by relevant clinicians from each

ward and department. This aimed to reduce the number of telephone calls to update the bed

status during the day. We observed these happening each day during our inspection.

The service had not taken steps to protect patient confidentiality at the reception desk.

Patients booked in at a reception desk. When streaming was also taking place in this area there

were occasions when two people stood at the counter side by side at the same time, creating a

risk that conversations could be overheard.

In the waiting area there were plenty of seats available where patients could be observed

by reception staff. The waiting area contained a television on the wall. There was a free phone

where patients could order a taxi and bus information was displayed. Up to date waiting times

were not displayed, in line with the emergency department developmental standards laid down by

the Royal College of Emergency Medicine 2017. There were toilets with disabled access and

vending machines, so patients could access drinks and snacks.

There was a separate children’s waiting area which had colourful murals on the walls and a

large number of toys and books. Not all people waiting in the children’s waiting area could not

be seen by the reception staff and there was no direct line of sight from the nurses’ station. CCTV

was in operation, but this was fed through to security staff and was not routinely monitored. There

was an emergency call bell but no signage to explain that it could be used to get assistance.

These areas were equipped for the care of children, were brightly coloured and a nice

environment for them to be in.

A significant number of emergency patients conveyed by ambulance were diverted from

Gloucestershire Royal Hospital to Cheltenham General Hospital when there was crowding

in the department. In the nine months from 1 January 2018 to 1 October 2018, there were 99

occasions when patients had been diverted from Gloucestershire Royal Hospital to Cheltenham

General Hospital, peaking during quarter one of 2018, when 45 occasions were reported. This

system was used as part of the trust’s escalation protocol, to prevent unsafe levels of crowding at

Gloucester. Whilst this improved patient safety, there was a negative impact on the patient’s

experience, with patients being further from home and creating difficulties for those without

transport arrangements. It also resulted in a sudden surge in activity in the emergency department

in Cheltenham General Hospital, which staff told us they sometimes struggled to cope with. There

was also a knock-on effect on ambulance availability due to increased journey times.

At both hospitals we observed patients who had been referred to the emergency

department inappropriately by other healthcare professionals. On one occasion, a patient

arrived for a dressing change following surgery in the ophthalmology department. We observed


this patient being advised to go to their GP. On another occasion, a patient with a minor skin

condition that had not responded to initial treatment was asked to attend the emergency

department by a GP, as they did not have capacity to see them at the practice. As the patient had

learning disabilities they saw him in the department. For patients not registered with a GP, a local

GP practice provided the Gloucester Health Access Centre, which was located near to

Gloucestershire Royal Hospital. Patients were signposted there by the streaming nurse when they

attended the hospital to access primary care services.

There were facilities available for patients who needed a quiet, private space to wait. Patients attending the department with the police or patients with a learning disability were triaged promptly and allocated the use of an interview room to avoid them waiting in the waiting room in full view of others.

When there was death in the department, staff told us they often used one of the cubicles in majors two for relatives or loved ones to be with the deceased. Whilst this had a door, so it could be closed off from the rest of the department, it was in a very busy area of the department where many people queued to be seen. It was also a working cubicle and one usually reserved to complete investigations or toileting for queuing patients who had not been allocated a cubicle. There was a more comfortable relatives’ room where relatives could sit if they preferred, however staff told us this was mainly used for those accompanying patients being treated in the resuscitation area.

For patients who self-presented to the emergency department, signage was not clear within

the hospital to locate the emergency department. Although there was one car park close to the

emergency department, there were many car parks and many entrances to the hospital. This

would prove difficult for those unfamiliar with the area.


Patients attending the department booked in at reception. There was no protected area to provide

confidentiality. We saw patients telling the receptionist their name, date of birth, address and

reason for visit. This could be overheard by patients standing behind them.

There was a waiting area for patients who self-presented to the emergency department, furnished

with seating, which was adequate at the time we visited. However, staff told us it filled up quickly

at times of peak demand, especially when patients were diverted to Cheltenham General Hospital

from Gloucestershire Royal Hospital.

There was a ‘child friendly’ space for children to wait and the adult area had vending machines for

people to buy snacks and drinks. Up to date waiting times were not displayed in the waiting area in

line with the emergency department standards laid down by the Royal College of Emergency

Medicine 2017. There were toilets available with disabled access.

Signage in the local area and other sources of information were not clear that the service

operated as a Minor Injuries Unit after 8pm. Despite a communications campaign being used,

staff told us that patients were confused about the services available at Cheltenham Emergency

Department and some did not realise that it did not offer a full range of services after 8pm. This

was not clear on the emergency department’s information page on the trust’s website. Staff also

described occasions when children were referred to the department after 8pm, when they should

be referred to Gloucestershire Royal Hospital and patients had told staff they were advised to

attend by the 111 service.

There was a steep slope at the entrance to the hospital, making it difficult for some patients to

access the emergency department. We observed a relative struggling to push their injured family

member up the slope to access the emergency department.


There was a comfortable relatives room in a quiet area of the corridor for those who had suffered

bereavement or needed a quiet place to wait. Patients with mental health needs were seen in a

separate assessment room.

Meeting people’s individual needs


The service complied with the accessible information standard. They identified patients with a

sensory loss and applied stickers to medical records to highlight this to staff, so they could adapt

their communication and care. Hearing aid batteries were available for patients who needed them,

and a sign language interpretation service was available.

An information leaflet was provided to carers with important information such as how to raise a

concern, how to claim an exemption from parking fees and arrangements for staying with a patient

overnight.

Teams were available at both hospital sites to support those with complex needs. During

our inspection the OPAL (older persons assessment and liaison) team were working in the

emergency departments to assess the needs of frail patients. They worked well with the

community rapid response service, which provided emergency short-term care to patients at

home, such as a sitting service. The trust was about to commence a new frailty assessment

service with extended operating hours and a wider scope. There were also specialist services

available to support patients living with drug or alcohol problems, the DART (drug and alcohol in-

reach team) was available from 9am until 5pm Monday to Friday. There was a separate team

responding to young people and children requiring mental health assessment and the trust was in

the course of appointing an independent domestic violence advisor (IDVA). The mental health

liaison team were stretched due to the number of referrals. Due to the high risk of patients within

the emergency department the service prioritised this over other work in the hospital. Senior

managers in the mental health trust were working with commissioners and the trust on developing

an all age service that would hopefully address the level of demand.

Services were available to support patients with learning disabilities. The learning disabilities

liaison team visited patients in the community to ensure that plans were in place to support the

patient’s needs during an emergency admission. Care plans were written, and a flag added to the

patient’s record so that staff knew where to look. Carers were supported through a helpline, they

could access help with parking fees, overnight accommodation and told of ways they could voice

concerns about the patient’s care. Examples of support provided included prioritising the patient to

minimise the time spent in the waiting area and making arrangements for carers to stay. The

liaison team did not always visit the department during an attendance but could be contacted by

carers or staff if there were concerns or if additional support was needed. A liaison team and

services were also available to support people living with dementia and their carers. 86% of staff in

the service had received specific training in the care of patients with dementia and there were

dementia champions in the department who tried to promote ways of enhancing the care of

patients with dementia, such as by putting up educational posters and updating the special

equipment available.

Frequent attenders to the emergency departments were overseen by the mental health

liaison team. They had introduced a high intensity worker for people with mental health needs

who frequently attend the emergency department. Since their introduction the number of

admissions has dramatically reduced, and the trust now comfortably meets the national CQUIN

target. Multi-agency care planning took place for frequent attenders and formal care plans were

available for the majority of these patients, with plans in development for the remainder. A flag


appeared on the booking system so that nursing staff were aware of those patients with individual

care plans.

A spiritual care team was available for patients, relatives and carers 24 hours a day. This

included a chaplain who would attend the emergency department. There was a multi-faith chapel

at both hospitals.

Emergency Department Survey 2016 The trust scored about the same as other trusts for all three Emergency Department Survey questions relevant to the responsive domain. Questions are scored on a scale from 0 to 10, with 10 being the most positive. Question – Responsive Score RAG Q7. Were you given enough privacy when discussing your condition with the receptionist?


Q11. Overall, how long did your visit to the emergency department last?


Q20. Were you given enough privacy when being examined or treated?




The service did not always take account of patients’ individual needs when they were in vulnerable circumstances. Staff did not always take appropriate steps to support patients living with dementia. The trust provided stickers and stamps with a purple butterfly to identify patients living with dementia. These were intended to go on their wrist band and their medical record. During our inspection we consistently found that these stickers or stamps were not being used. For example, when discussing one patient, a member of staff confirmed that one had not been used for a patient we observed and, when asked, confirmed the stickers were used only sometimes and they didn’t have any in the department. Another staff member later found them.

Posters were displayed in the emergency department to remind staff to use ‘This is Me’

forms. These allow carers to record information about patients with impaired cognitive ability or

communication difficulties, such as their preferences, routines and personality. They were

intended to enhance the care provided to people living with cognitive impairment.

Staff told us some patients arrived with the forms completed by care home staff, however,

they did not consistently complete the forms in the department. Some staff understood they

were completed on the wards. On one occasion we asked whether a patient, who was living with

dementia, who had been in the department for over two hours, had arrived with a ‘This is Me’ form.

The patient’s documents had not been checked and the nurse did not know whether the patient

had arrived with a form. This meant that that staff may not be well informed of patients’ particular

needs and miss opportunities to provide appropriate support to patients, who may be anxious,

agitated and disorientated in an unfamiliar environment.

A ‘dementia telly’ was available in the department, which could be used to distract or

comfort agitated patients. Staff reported this tool was very effective in calming those who were

anxious or agitated. There was a range of films, appropriate to all age groups and on a wide range

of subjects. We did not see this used during the inspection, but staff told us they had used it and it

to very good effect. Other tools were available in a ‘dementia box’ to support people living with

dementia, such as colouring books and twiddlemuffs (used to occupy patients’ hands with buttons


and ribbons). However, we did not observe these tools being used during the three days we spent

in the emergency department, even though a number of patients living with dementia attended the

department.

The emergency department could access services which offered sign language

interpretation, as well as foreign languages, to support those whose first language was not

English, to ensure they fully understood what was being said.


The service took account of patients’ individual needs. Staff provided support to people with

complex needs, such as people with mental health needs, and patients living with dementia.

However, interpretation services could be improved.

We observed staff using the purple butterfly stamp on the clinical records of patients in the

emergency department, so they could be identified as living with dementia. ‘This is Me’

forms were not available in the emergency department. During the inspection and we did not have

the opportunity to observe the care of patients living with dementia to see whether existing forms

were reviewed to enhance the care provided.

Patients with mental health needs were cared for in an assessment room. The liaison team

was based at Gloucestershire Royal Hospital, but staff travelled to and from Cheltenham General

Hospital by bus, which sometimes delayed assessment times.

Although translation and interpretation services were supposed to be available to patients

whose first language was not English, staff reported problems with accessing these

services. The reception staff we spoke with said they would usually ask an accompanying person

to translate for the patient. They did not know how to access telephone interpretation services. A

cleaner had written some questions in a language other than English to help with the booking in

procedure, but staff were not able to find these were not able to be found.

Access and flow

Patients were not always able to access care and treatment in a timely way and in the right

setting. Waiting times in the emergency department had significantly improved since our last

inspection but the trust was still failing to meet national standards in relation to the time patients

spent in the emergency department, and the time they waited for their treatment to begin.

Performance against national targets

The trust’s performance had declined against this standard since our last inspection and

was generally worse than the England average. The Royal College of Emergency Medicine

recommends that the time patients should wait from time of arrival to receiving treatment should

be no more than one hour. Up to date waiting times were not displayed, in line with the

emergency department standards laid down by the Royal College of Emergency Medicine 2017.

Only 34.5% of patients had their treatment commenced within an hour during 2017/2018. The

trust met the standard in only two months in the 12 months prior to the inspection.

Median time from arrival to treatment from August 2017 to July 2018 at Gloucestershire

Hospitals NHS Foundation Trust



Time of arrival to treatment - Gloucestershire Royal Hospital

In the six months prior to the inspection the percentage patients seen at Gloucestershire

Royal Hospital within 60 minutes ranged from 27.7% to 33.0% and the average time to

treatment ranged between 63 and 83 minutes. The trust also monitored the numbers of patients

waiting longer than six hours for their treatment. The worst performance at Gloucestershire Royal

Hospital was in March 2018, when 9.1% patients waited longer than six hours. The hospital was

taking steps to improve their performance in this area by employing physician’s assistants to

support the work of the medical team. However, medical staff told us a significant contributor to

the delay in initiating treatment for patients was crowding in the emergency department. On many

occasions, there was simply no physical capacity for doctors to assess and treat patients who

were queuing in the corridor.

Time of arrival to treatment - Cheltenham General Hospital

At Cheltenham General Hospital performance was slightly better, with monthly

performance ranging from 38.3% to 45.1% and the average time was 52-69 minutes. In the

last six months, there were two months (August and June 2018) where patients (1.2%) waited

over six hours for their treatment to begin.

Percentage of patients admitted, transferred or discharged within four hours (all

emergency department types)

The Department of Health’s standard for emergency departments is that 95% of patients should

be admitted, transferred or discharged within four hours of arrival in the emergency department.

The systems to manage flow through the hospital had improved significantly since our

last inspection, however the department was still challenged as the numbers of patients

who required admission often exceeded the available beds. Effective site management and

collaborative working with the speciality teams ensured patients could be allocated a bed in a

timely way much of the time.

The Trust was meeting the 4-hour standard trajectory agreed with NHS Improvement and NHS

England, this is 90%. The trust has achieved this standard for four quarters in a row.


Cheltenham General Hospital has consistently been a top performer in relation to the four-hour

target.

Four-hour target performance – last six months at site level

Cheltenham General Hospital Gloucestershire Royal

Hospital

March 2018 96.5% 82.3%

April 2018 97.8% 89.1%

May 2018 98.1% 88.1%

June 2018 96.3% 91.8%

July 2018 96.9% 88.4%

August 2018 96.0% 87.4%

Staff attributed their improvement to better collaborative working with colleagues in the

unscheduled care team and better trust wide engagement overall. A task and improvement

group had been formed to review and address issues with patient flow. The group had initially

reviewed the problems faced in the emergency department and unscheduled care but then

included the whole hospital.

The improved flow in the departments was further demonstrated by sustained improved

performance for patients waiting more than four hours from the decision to admit until

being admitted. From August 2017 to July 2018 the trust’s monthly percentage of patients waiting

more than four hours from the decision to admit until being admitted was better than the England

average.

Percentage of patients waiting more than four hours from the decision to admit until being

admitted - Gloucestershire Hospitals NHS Foundation Trust

(Source: NHS England - A&E SitReps).

Over the 12 months from August 2017 to July 2018, only one patient waited more than 12 hours

from the decision to admit until being admitted. This was in February 2018.

(Source: NHS England - A&E Waiting times)


Percentage of patients that left the trust’s urgent and emergency care services without

being seen - Gloucestershire Hospitals NHS Foundation Trust

From July 2017 to June 2018 the monthly percentage of patients that left the trust’s urgent and

emergency care services before being seen for treatment was similar to the England average.

In the most recent month, June 2018, the percentage of patients that left the trust’s urgent and

emergency care services before being seen for treatment was 2.8%, compared to the England

average of 2.4%.


Median total time in A&E per patient (all patients)

From July 2017 to June 2018 the trust’s monthly median total time in A&E for all patients was

similar to the England average.

In the most recent month, June 2018, the trust’s monthly median total time in A&E for all patients

was 155 minutes compared to the England average of 148 minutes.



Patients with mental health needs were not always promptly assessed by mental health

practitioners. The service specification agreed with the provider of this service was for patients to

receive an assessment within two hours. However, guidance from the National Institute for Health

and Care Excellence recommends a response should be within one hour of receiving the referral.

There were around 200 adult referrals to the mental health liaison team each month, around 25%

of these were for older persons and the remainder were for working age adults. The majority of

referrals (approx. 80%) were from Gloucestershire Royal Hospital.

Managers were monitoring all parts of the pathway to identify delays. Trust-wide, the

percentage of patients seen by the mental health liaison team, following urgent mental

health referral, within two hours, ranged from 35% and 72%. In the last quarter the average

was 67%. This data was not broken down to individual hospitals, however the trust had identified

that most challenges were experienced at Cheltenham General Hospital at night. We reviewed

some of the cases where patients had extended waits. Some of these were due to medical

reasons, such as the patient being sedated or intoxicated. However, we reviewed two cases in

July 2018, one patient arrived in the emergency department at 4.20pm and was assessed as very

urgent; but they were not seen by the mental health liaison team until 10.15pm, a total wait of five

hours and 47 minutes. Another patient, who was assessed as urgent, waited four hours and 40

minutes to be reviewed by the mental health liaison team. In many of these cases, there was an

accumulation of delays in the pathway, both prior to and after referral to the mental health team.

The trust was aware of the delay for some of these patients and was hoping to train advanced

nurse practitioners in the future to assess patients to reduce the time before referral.

Emergency department staff expressed concerns that the mental health liaison team did

not always respond quickly. During the inspection we observed the referral system for patients

suffering from mental health illness. There were clearly some issues with communication between

the emergency department staff and the mental health liaison team. For example, we observed a

nurse bleeping the on call mental health worker and then leaving the phone to attend to other

work. Other emergency department staff did not answer the phone initially when it rang, and when

it was answered did not know why the mental health team head been called, this added delays in

the communication before the patient could be seen. Another patient was noted to have been

waiting for a mental health assessment following an overdose for seven hours. Emergency


department staff had not notified the mental health team of the patient, with different staff

assuming others had done the referral. The mental health liaison team responded to the referral

within 10 minutes of the referral finally being made.

Learning from complaints and concerns


The service treated concerns and complaints seriously, investigated them, learned lessons

from the results, and shared these with all staff. People who used the service knew how to

make a complaint or raise concerns. Leaflets were available in the emergency department

providing information about how to raise a concern or make a complaint. This included contact

information, how to access support with the complaint and the process to follow if people were not

happy with the department’s response to the complaint. Special liaison teams provided extra

support for people living with cognitive impairment, such as patients living with dementia and

learning disabilities. d Information was provided about how to access the patient advice and liaison

service (PALS)

Complaints were handled confidentially, and formal records were kept. We reviewed

complaint responses, which were written clearly, answered the concerns and written in a

considerate manner.

Medical staff that complaints they reviewed in monthly clinical governance meetings. We

asked to review the minutes from these meetings to understand the nature of the discussions, but

they were not provided.

Summary of complaints and compliments

From April 2017 to March 2018 there were 157 complaints about urgent and emergency care

services. The trust took an average of 37 working days to investigate and close complaints. This

is not in line with their complaints policy, which states complaints should be closed within 35

working days.

The four most common subjects of complaints are shown in the table below:

Complaint Detail Count of Complaints

Clinical treatment 54

Patient Care (Nursing) 22

Communications 18

Admission and discharges 17



services at Gloucestershire Royal Hospital. The site took an average of 37 working days to

investigate and close complaints. This is not in line with their complaints policy, which states

complaints should be closed within 35 working days.

Complaint detail Count of complaints





Communications 14

Values and Behaviours (Staff) 11

Waiting Times 11

Prescribing 6

Other 3

Privacy, Dignity and Wellbeing 3

Facilities 2

End of life care 1

Trust admin/policies/ procedures

including patient record

management

1

(blank) 1




services at Cheltenham General hospital. The service took an average of 38 working days to

investigate and close complaints. This is not in line with the trust’s complaints policy, which states

complaints should be closed within 35 working days.

Complaint Detail Count of Complaints



Communications 4


Access to treatment or drugs 1



Is the service well-led?

Leadership


The leadership structure comprised three senior leaders, who reported to the divisional

management team for unscheduled care. There was a single assistant business manager and

clinical lead covering both hospitals and a matron at each site. Divisional leadership was provided


by a chief of service for unscheduled care. Each of the medical consultants and some of the senior

nurses had taken additional lead responsibilities, such as governance, audit and education. There

was a monthly emergency department operational meeting, where there was discussion on a wide

range of day to day operational matters, such as performance and workforce. This was chaired by

the clinical lead and attended by the other two senior leaders, along with all senior nursing and

medical staff.

There was strong support for the medical team and junior doctors told us they received

effective supervision and education. Feedback from junior doctors had continued to be positive

about their training experiences in the emergency departments.

Senior leaders and directors met monthly at the Emergency Care Board, which was

attended by the Chief of Service and the Speciality Director for Unscheduled Care. Actions

for improvement were agreed and monitored.


In general, the department’s management team understood the challenges to quality,

performance and sustainability, and had identified the actions needed to address them. At

the time of our inspection the matron had been in post for a few months, but was receiving support

from the former matron, who was now the new associate director for unscheduled care. Overall,

there was strong strategic and operational leadership of the department with people who had the

skills and knowledge to lead effectively and motivate staff. Managers were visible and well

respected by staff, who found them approachable.

The chief of service, who joined in April 2017, had led a number of improvements to referral

pathways and increased collaboration between medical teams in unscheduled care. All

medical staff we spoke with reported relationships as having improved, pathways worked better

and there was an improved sense of collective responsibility. The same improvements were not

yet evident with pathways to other specialities, but senior leaders reported they were confident this

would be achieved. Much of this growth in confidence was attributed to a new chief operating

officer, described by one as ‘inspirational’. Leaders encouraged appreciative and supportive

relationships among staff. Staff and leaders spoke with each other professionally and respectfully.

The trust had introduced changes to the leadership structure and management of the

department since our last inspection. This included the recruitment of four additional band

seven registered nurses to act as flow coordinators, and an improved process of board round and

emergency department sit reps as well as additional support from senior management in the trust.

Despite this, the matron spent time in the emergency department supporting the nurse co-

ordinator which was not always effective. They generally worked effectively to organise the

care and flow of patients and there was a strong sense of teamwork. However, there was limited

day to day oversight for matters relating to the safety or quality of care for patients. When

challenges or unexpected events occurred, nurse co-ordinators sometimes lacked assertiveness

and generally did not step forward to resolve issues or situations developing in the department.

We observed several occasions during our inspection, during different shifts, when

medical staff stepped in when non-medical issues occurred within the department. Whilst

the issues were successfully dealt with, senior medical staff were spending their time on matters

not requiring their skill or experience. We also highlighted simple safety issues to the nurse co-

ordinator on two occasions, including a visiting staff member in the department who was not bare

below the elbows and harmful chemicals not locked away, but no immediate action was taken.



Managers had the right skills and abilities to run a service providing high-quality sustainable care. Although some areas of performance still needed to improve, they understood the challenges to quality, performance and sustainability. There was also a good standard of day to day oversight and leadership in the department so that patients generally received a high standard of care

Leadership was strong in the department with people who had the skills and knowledge to lead effectively. Department leaders, including the nurse co-ordinators were visible, had very good relationships with all staff and showed clear leadership. The clinical lead and the medical team worked at both hospital sites which ensured there was consistency in the medical leadership between the two hospitals.

There had been less progress in improving pathways between the emergency department

and the speciality assessment units. Whilst there was a desire to make similar improvements,

efforts were concentrated in the areas of highest risk in the trust and this was at Gloucestershire

Royal Hospital due to higher levels of crowding.

Vision and strategy


There were improvement plans in relation to quality and performance. These improvement

plans appeared achievable and sustainable and included mental health care. However, whilst the

hospital’s vision, mission and strategic objectives had been planned and published to staff and the

public, this had not been undertaken in any formal way at department level. Staff had been

consulted regarding some of the changes in the department and asked for feedback and ideas.

We did not see evidence of involvement of patient groups or service users when developing plans.

There had been a recent review of improvement initiatives to ensure they joined up with the

department’s future goals. There were clear priorities and efforts were concentrated to a fewer

number of agreed projects to ensure improvement was meaningful and sustainable. Examples of

such projects included improvement to front-door streaming, which had included initiatives such as

the GP working in the emergency department in Gloucester and opening the Acute Medical Initial

Assessment unit (AMIA), improving these admission pathways.

There had been significant progress over the previous 12 months and success in delivering

improvements, supporting the current and future vision for the department. The whole

medical team within the unscheduled care division were working more cohesively and supporting

each other in delivering timely, high-quality care in each of the departments. This included the

emergency department, acute medical unit, acute medical admissions unit and ambulatory

emergency care.

Senior leads were clear about where the next phase of improvement would be focused. This

included improvements to the other admission pathways, including surgery and orthopaedics and

improved streaming at the front door. There was good liaison between managers of the

emergency department and the mental health liaison team with a shared vision of how mental

health services should develop.


There was uncertainty at staff and leadership level about trust’s future intentions for the

emergency department. Since 2013 the department had been downgraded to a minor injury unit

(MIU) between 8pm and 8am. However, the signage outside the hospital and the trust’s website

did not make this clear, which meant some of the public were unaware and staff were uncertain

whether this was a permanent arrangement. The downgrade had been due to a shortage of


medical cover; however staffing plans to restore medical cover at night were not actively

discussed. There was now wider discussion, as part of the area’s sustainability transformation

plan, about how future emergency care would be delivered. Staff were therefore uncertain about

the vision for the future and senior leads had no real objectives for the department, other than

those needed to maintain good quality care. They had, however, as a local team, determined

their focus for the next year to improve patient care and experience. Examples of planned

improvements included increasing the use of the butterfly scheme to identify patients living with

dementia, pressure ulcer care, communication with patients and improved safeguarding

detection. There was a ‘message of the week’ board in the staff room to encourage staff to make

improvements in certain areas. During our inspection the message was to remember to have a

low threshold when assessing pain in those with impaired communication.

Culture


Staff we spoke with felt supported, respected and valued. We saw respectful and cooperative relationships and effective teamworking, on nearly all occasions, between staff at all levels and all disciplines.

There was a professional culture, centred on safety and the needs and experience of

patients. Good multidisciplinary teamworking meant everyone felt important within the

team and everyone’s ideas and thoughts were listened to. This was evident in training,

meetings and quality improvement projects, where staff from a range of roles were included and

each person’s input was of equal value. One member of staff described how they no longer felt

blamed as a team for the challenges in the emergency department. There was more support from

the senior leadership team and they felt their hard work was now recognised. Other staff described

how they no longer felt isolated with the problems in the emergency department, they felt the

whole hospital was sharing the burden and helping to find solutions.

The emergency departments had introduced a FERF (favourable event reporting form). This

encouraged staff to report positive stories to the management team, when they saw their

colleagues demonstrating excellence in their work. Staff had engaged with the scheme well and

spoke very positively about the impact it had on their morale. The trust had also recently

introduced a recognition scheme, known as GEM (Going the Extra Mile), for which a staff member

from the emergency department had been nominated, and an annual staff awards scheme.

The culture at both emergency departments encouraged openness and honesty and

learning and improvement. Staff felt able to speak up about things concerning them, without

fear, and they felt able to challenge decisions when they felt they needed to. There was a very

strong focus on quality improvement projects and emphasis on making them relevant to the

areas needing improvement. There was good training available for staff in undertaking quality

improvement projects and structured judgement review and a good level of support was

provided.

The culture in the emergency departments promoted learning. Nursing staff told us they

were included in some of the training activity for junior doctors. Senior medical staff took time to

explain their clinical decisions and treatment, so the nurses were kept informed. There was an

ongoing programme of continuous professional development and staff had the opportunity to

suggest areas they wanted training in.

Most staff told us they felt safe working in the emergency department and could call security staff


when it was needed. Security staff and porters were trained in restraint or ‘safe hold’. Staff had

been given personal alarms, however some staff we spoke with still had them in their tray and

they had not received information or training when they were handed out. However, no staff told

us they did not feel secure when at work.

Staff said they felt supported by their colleagues. Following emotionally challenging incidents,

the emergency department conducted debriefs. These were often multidisciplinary, although one

consultant told us this didn’t always happen as often as they would like, due to department

pressures. Staff we spoke with did not always know where to get additional welfare support if

they needed it.


Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose, based on shared values. Staff were professional and positive at work and felt well-supported and a close-knit team. The department had developed a culture where people felt comfortable reporting things that had gone wrong.

Staff were proud of their department. Each person knew their role and what was expected of

them and staff worked well together as a multidisciplinary team. The department was very busy

most of the time. In order to keep on top of tasks relating to treatment and safety, there was less

time for interaction with each other or with patients. However, the team met regularly at staff

meetings and relationships were all positive and staff described “a good team spirit”.

There were occasions of friction between nursing staff and the psychiatric liaison team;

this usually related to timeliness of responses to requests for patient assessment. During

the inspection we found this was often caused by misunderstanding or difficulties in contacting

each other.


Managers promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff were professional and nurtured excellent relationships with their patients. Staff also felt well-supported and a close-knit team. The department had developed a culture where people felt comfortable reporting things that had gone wrong.

The working environment was cheerful and positive, with good relationships between staff

at all levels. Staff had concerns about the future of the emergency department as there were

ongoing discussions about reconfiguring Gloucestershire’s emergency care provision. This had

caused uncertainty over what their role would be in 12 months’ time. However, this did not

appear to have affected morale during the working day. Staff remained positive they had a future

in the department, although they accepted there would be changes.

Governance


There was a systematic approach to continually improving the quality of its services and

safeguarding high standards of care, by creating an environment in which excellence in clinical

care would flourish. The management had good oversight and knew where they needed to improve.

The governance framework used in the department seemed to interact effectively at the different

levels, although we were unable to fully evaluate the clinical governance process.

There was an effective governance framework to support the delivery of good quality care.

There were clear committee and meetings structures. Monthly ‘tri’ meetings involving the three

senior leaders in the department took place and there were fortnightly unscheduled care senior


leaders’ meetings, chaired by the chief of service. These meetings fed into the medical divisional

monthly board meetings. The levels of governance interacted well with each other and also

interacted effectively with the various other assurance processes used. These included incident

reporting, mortality and morbidity reviews and audit. Information about quality, safety and

performance was collected and used to monitor and manage quality and performance. Data

about a range of measures was reported through a dashboard.

At department level, there was a consultant clinical governance lead within the department

and departmental clinical governance meetings were held monthly. We asked for copies of

minutes for these meetings to understand the subjects discussed, but they were not provided.

Mortality and morbidity meetings also took place each month to discuss patient deaths in the

department. Usually about five cases were reviewed, using a subjective judgement review (SJR)

and findings presented to colleagues. Minutes were issued to all staff and six-monthly

newsletters sent with important learning points. We reviewed some cases subjected to a SJR and

there was a clear audit trail of the findings, learning and actions taken to improve.

There was an infection control team which provided oversight for infection prevention and

control arrangements. Divisional action plans were drawn up quarterly and reviewed at the

infection control committee, chaired by the director of nursing. The infection control strategy

included a comprehensive system of audit, reported through quarterly reports and reviewed by

divisional board.



These systems looked at current performance and risks to future performance and service

delivery. There was a systematic programme of audit, which monitored quality, operational

performance and financial processes. This ensured there was oversight at each level of leadership

from department level to board level, effective collection and analysis of data and an effective

committee structure.

There were robust arrangements for identifying, recording and managing risks.

Departmental risks were captured in a risk register for the medical division and these were

reviewed regularly, and detailed risk mitigation plans were documented. There was a clear risk

escalation process, with high scoring risks reviewed at divisional meetings. New risks were

reviewed at the unscheduled care senior leaders meeting and monthly quality board. Generally,

there was alignment between the recorded risks and what staff said was ‘on their worry list’.

Whilst there had been high levels of focus on improving the trust’s four-hour performance, there

had been limited attention paid to the bigger risk of undiagnosed patients waiting for too long in

the emergency departments for an initial assessment, treatment and investigations. These delays

occurred across both hospital sites and had not improved since the last inspection. This issue

was of most concern to medical staff and was on the risk register with a score of 8 (high risk) and

had been escalated. We could not identify any specific improvement plans that would lead to

sustainable improvement, except for improvements to the streaming process and increasing the

capacity of transfer teams. However, most of the same problems existed also at Cheltenham

General Hospital where streaming did not happen, and insufficient porter staff were not reported.

Potential risks were considered when planning services, for example seasonal or other

expected or unexpected fluctuations in demand, or disruption to staffing or facilities.

There was a winter plan for 2018/2019 and, although they expected significant challenges,


department leads told us they felt more confident going into the winter months than in previous

years. There was an urgent care action plan, looking at the proactive work required to handle the

increased expected activity, such as increasing capacity within the transfer teams, better use of

direct admission pathways and a review of the GP streaming trial.

Managing information


The service collected, analysed, managed and used information well to support all

activities, using secure electronic systems with security safeguards. There was a holistic

understanding of departmental performance. Data was used to lead discussions about quality,

operations and finances and there were effective systems for the collection, display and analysis

of information to support the delivery of good care.

Incident recording tools were used effectively to ensure any issues around quality of care

were recorded, analysed and fed into other quality assurance processes, such as mortality

and morbidity, audit and clinical governance. Record keeping was also of a high standard, so

the department could demonstrate how and where their processes interlinked. Data was also

captured to support submissions to national audit or notification bodies.

IT systems within the department were reliable and easy to use. There were sufficient

computer terminals for medical and nursing staff to complete records. There was a large

digital display monitor in the department, but this was not in use. Staff had to keep revisiting the

computer terminals to check the location of patients, however there were sufficient work stations

for them to do this.

Nurse co-ordinators used this information to support their management of the department

and movement of patients onto the wards. Data was used effectively in bed meetings to

discuss the flow of patients from the emergency department to the in-patient wards. Reports were

analysed and discussed at a range of meetings, so staff at all levels understood the department’s

performance. The exception to this was for professional standards for specialty teams (the

standard set for who reviews patients in the emergency department and the timescale for

response). Staff in the emergency department reported some delays, but no data was recorded to

ensure there was appropriate oversight by senior managers.

Regular reports were produced with information about quality and performance, so

department leads could monitor the safety of the department. When concerns about data

integrity had arisen, improvements were made to ensure all people involved in the monitoring and

management of the service were working from the same set of data.

Confidential records were kept secure and there were robust arrangements to ensure

identifiable patient information was only shared when appropriate. Computer terminals were

password protected and confidential information was not displayed so it was visible to the public.

There were systems to ensure patients were correctly identified and on most occasions, these

were followed by checking wrist bands and labelling records. We saw a few occasions when

patient labels and wristbands were left around the nurses’ station at Gloucestershire Royal

Hospital and the labelling of blood happened away from the patient. We also saw one occasion

when a set of records for a previous patient was left in a cubicle occupied by a new patient. These

issues carried a risk a patient may be misidentified for tests requested or specimens labelled

wrongly.


Engagement


The service engaged with patients and staff to plan and manage services and there was

some collaboration with partner organisations. There were several processes by which the

hospital gathered people’s views and understanding of their experiences. The trust captured

patient feedback of service users through the friends and family questionnaire. During our

inspection, although posters were displayed in the waiting areas, we did not see paper

questionnaires in the emergency departments and reception staff were unable to locate them.

Reception staff explained patients received a text on their mobile device asking for

feedback. Although this was a good use of digital technology, using this method exclusively risked

excluding some people from the opportunity to give their feedback. This included those less

familiar or without access to digital technology and those who struggle to use mobile devices due

to physical or cognitive impairment.

The trust measured the positive and negative feedback responses and used the score as a

measure of quality. Themes were displayed on a poster in the staff rooms and were sometimes

discussed at department meetings. In the last two quarters the percentage of positive responses

had remained reasonably stable, with the lowest score 82.7% and the highest score 85.9%. The

trust’s departmental target for positive responses was 86% and the national average was 84%.

Although the trust monitored the positive and negative results, there was little evidence of patient

feedback being discussed or considered by department leads when making decisions about the

service. We could not identify many improvements made as a direct result of feedback from

complaints or the patient survey. The trust planned to purchase new software over the next year to

improve their insight into patient experiences. The trust had, however, ensured the board of

directors heard directly from patients through patient stories and had responded directly to many

of the issues raised. This had recently explored issues in the emergency departments, such as

access to call bells and phone chargers for waiting patients and the need to increase porter staff.

Improvements had been made in response to many of these issues.

There were designated helplines with liaison staff for patients and carers living with

dementia and learning disabilities. The learning disabilities team in particular worked pro-

actively to engage with people with learning disabilities to ensure the emergency department was

equipped and designed to support them when they needed emergency care. In addition, patients

and carers were given the details of the patient advice and liaison service if they felt their voice

was not being heard.

Staff were actively engaged through staff engagement forums, so their views were reflected

in the planning and delivery of services. There had been a staff survey within the last 12

months and a comprehensive action plan completed at divisional level to address key findings in

areas such as staff health and wellbeing, and staff experiences of harassment, bullying or abuse.

There were healthy and collaborative relationships with external partners, such as the local

ambulance service, mental health care providers and the commissioning group. In relation

to the trust’s external contract for mental health support, bi-monthly liaison meetings took place in

which detailed reports were reviewed about referrals and service delivery.




The trust was committed to improving services by learning from when things went well and

when they went wrong, promoting training, research and innovation. There was a sense of

collective responsibility throughout the medical team for continuous learning and improvement.

Staff at all levels participated in audit and quality improvement activity and there were designated

leads for review of guidelines, quality improvement, audit and governance. The trust’s key

priorities for quality improvement were laid out in the annually published quality account.

The emergency departments were involved in appropriate national and local research

projects. In addition to the audits from the Royal College of Emergency Medicine, the service was

also involved in the major trauma ‘TARN’ audits, stroke audits ‘SSNAP’, and chest pain ‘MINAP’

audit. They were also involved in various research trials: NOPAC (looking at the benefits of using

tranexamic acid for the treatment of nose bleeds), CRASH3 (looking at the benefits of using

tranexamic acid for the treatment of head trauma), and RAMPP (looking at ambulatory

management of pneumothorax). Locally there was research and quality improvement work

happening, such as looking at thrombolysis pathways for STEMI (a type of heart attack) and

evaluating the use of x-ray in acute coronary syndrome to reduce unnecessary x-rays. Medical

and nursing staff described the department as constantly reviewing and changing their practice.

Quality improvement was well-supported by the trust’s safety and quality improvement

academy. Staff had been trained in recognised methodology and involvement was

expected of all training doctors. Projects were mostly multidisciplinary to ensure full

departmental engagement. There was a clear alignment between the quality improvement projects

and areas identified as needing improvement through audit, incidents and inspection. For both

hospital sites, monitoring and supervision of quality improvement was provided by a lead

consultant and through clinical governance meetings.

Medical staff received training in structured judgement review, which was a recognised

methodology used by medical staff for mortality and morbidity reviews. The hospital had

been working with external improvement organisations, such as GIRFT (getting it right first time).

The hospital was used as an exemplar site for good practice for its work in reorganising trauma

and orthopaedics to be more responsive to the needs of orthopaedic trauma patients. They had

also worked with ECIST (emergency care intensive support team) to review department staffing

levels.

Medical care (including older people’s care)


Medical care services provided by Gloucestershire Hospitals NHS Foundation Trust are carried

out at two hospital sites: Gloucestershire Royal Hospital and Cheltenham General Hospital. The

medicine clinical division managed the services at both sites. The medicine division included the

following specialities: neurology, stroke, care of the elderly, dermatology, endocrinology, diabetes,

rheumatology, gastroenterology, endoscopy, renal, cardiology and respiratory. Unscheduled care,

including the acute medical units and ambulatory care units were included in the medicine division.

There are 462 medical inpatient beds located across 20 wards across both hospital sites.

A site breakdown can be found below:


Gloucestershire Royal Hospital: 320 inpatient beds across 13 wards

Cheltenham General Hospital: 142 inpatient beds across seven wards

The trust had 78,438 medical admissions from June 2017 to May 2018. Emergency admissions

accounted for 34,060 (43.4%), 1,499 (1.9%) were elective (planned care), and the remaining

42,879 (54.7%) were day case.

Admissions for the top three medical specialties were:

General medicine - 28,704 admissions

Medical oncology - 20,522 admissions

Gastroenterology - 11,860 admissions

The chart below shows the activity at the trust compared with other NHS trusts.



Cheltenham General Hospital has 142 inpatient beds across seven wards. The hospital medical wards provide care in the following specialities: acute medicine, cardiac and coronary care, respiratory, gastroenterology, oncology and older people’s care. The site also has a cardiac catheterisation laboratory, an endoscopy unit and an ambulatory emergency care unit.

During the inspection we visited all seven inpatient wards and most specialist areas including: Acute Medical Unit Ambulatory Emergency Care unit Avening (respiratory ward) Cardiac catheterisation laboratory Coronary care unit and cardiac wards Lilleybrook and Rendcomb (oncology wards) Ryeworth and Woodmancote (older people’s care wards) Snowshill (gastroenterology)


78,438 spells in Gloucestershire Hospitals NHS Foundation Trust


Gloucestershire Royal Hospital has 320 inpatient beds across 13 wards. The hospital medical

wards provide care in the following specialities: acute medicine, cardiac and coronary care

respiratory, gastroenterology, neurology, stroke, renal and older people’s care. The site also has

an endoscopy unit, an ambulatory emergency care unit and a medical day unit.

During our inspection we visited the follow wards and units: Ambulatory Emergency Care unit

Acute Medical Unit

Cardiology and coronary care unit

Endoscopy unit

4A (general medical ward)

4B (general medical and older people’s care)

6A and 6B (stroke unit)

7A (gastroenterology ward)

7B (renal ward)

8A (neurology and stroke)

9B (older people’s care)

Medical day unit


Mandatory training

The trust provided mandatory training in key skills to all staff and had processes to ensure

staff completed it. Most staff were compliant with their mandatory training updates, although not

all courses were meeting the trust target. Trust mandatory training modules were in a range of

subjects relating to safety systems, processes and practices. Training was a mix of e-learning and

face to face sessions.

The trust kept centralised records of staff compliance with statutory and mandatory

training and ward managers were responsible for tracking staff compliance. Staff told us

they received email reminders when training was due, and managers discussed mandatory

training during appraisals. We saw ward meeting minutes included reminders to staff to complete

mandatory training.

Senior leaders told us the trust was reviewing mandatory training data as they were not

confident the data was correct, and the results were possibly better than indicated. The aim

of the review was to ensure staff who had left the organisation were not included in mandatory

training compliance reports.

The trust provided staff with training in recognition and treatment of mental health

conditions. Staff had access to face to face training on the safe management of violence and

aggression from the dementia liaison team or learning disability nurses. The trust overall dementia

strategy included staff training in line with the 2009 National Dementia Strategy. Recent updates to

the training included the addition of delirium awareness for nursing staff. Staff on both sites

described how people living with dementia had shared their experiences on some of the training

courses, which staff told us was very useful in helping them understand the challenges patients,

relatives and carers face.

Mandatory training completion rates

The trust set a target of 90% for completion of mandatory training. The compliance data below for

the training courses is for the 12 months up to June 2018.


In medicine the 90% target was met for six of the 10 mandatory training modules for which

qualified nursing staff were eligible. A breakdown of compliance for mandatory training

courses as of June 2018 at trust level for qualified nursing staff in the medicine division is shown

below:

Name of course

Staff

trained

Eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)











In medicine the 90% target was met for one of the nine mandatory training modules for

which medical staff were eligible. A breakdown of compliance for mandatory training courses

as of June 2018 at trust level for medical staff in medicine is shown below:

Name of course

staff

trained

Eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)











At Cheltenham General Hospital the 90% target was met for eight of the 10 mandatory

training modules for which qualified nursing staff in medicine were eligible. Of the

remaining two courses, one was almost at target and the other, manual handling of people,

needed improvement. A breakdown of compliance for mandatory training courses as of June

2018 for qualified nursing staff in medicine at Cheltenham General Hospital is shown below:

Name of course

Staff

trained

Eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)









Information Governance 145 159 91% 90% Yes



At Cheltenham General Hospital the 90% target was met for three of the nine mandatory

training modules for which medical staff in medicine were eligible. Of the remaining six

courses, three were almost at target and the other three, adult basic life support, manual

handling of people and information governance, needed improvement. A breakdown of

compliance for mandatory training courses as of June 2018 for medical staff in medicine at

Cheltenham General Hospital is shown below:

Name of course

Staff

trained

Eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)











At Gloucestershire Royal Hospital the 90% target was met for five of the 10 mandatory

training modules for which qualified nursing staff in medicine were eligible. All five

remaining courses were almost at target. A breakdown of compliance for mandatory training

courses as of June 2018 for qualified nursing staff in medicine at Gloucestershire Royal Hospital

is shown below:

Name of course

Staff

trained

Eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)











At Gloucestershire Royal Hospital the 90% target was met for one of the nine mandatory

training modules for which medical staff in medicine were eligible. Of the eight remaining

courses, one was almost at target and the other seven, needed improvement. A breakdown of

compliance for mandatory training courses as of June 2018 for medical staff in medicine at

Gloucestershire Royal Hospital is shown below:


Name of course

Staff

trained

Eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)










(Source: Routine Provider Information Request (RPIR) – Training tab)

Safeguarding

Staff understood how to protect patients from abuse and the service worked well with other

agencies to do so. Staff had training on how to recognise and report abuse and they knew how to

apply it.

Safeguarding training completion rates

The trust set a target of 90% for completion of safeguarding training. The compliance rates of the

training courses are for the 12 months up to June 2018.

Trust level – medicine division

In medicine, the 90% target was met for one of the four safeguarding training modules for

which qualified nursing staff were eligible. Compliance with the remaining three courses

needed some improvement but were quite close to the trust target. A breakdown of compliance

for safeguarding training courses as of June 2018 at trust level for qualified nursing staff in

medicine is shown below:

Name of course

Staff

trained

Eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)

Safeguarding Children (Level 2) 408 438 93% 90% Yes

Safeguarding Adults (Level 2) 374 438 85% 90% No


Safeguarding Children (Level 1) 360 438 82% 90% No

In medicine, the 90% target was met for none of the five safeguarding training modules

for which medical staff were eligible. For Safeguarding Children (Level 3), there were only 4

staff eligible for the training across the medicine division. This should therefore be considered

when interpreting the completion rate for this training course. A breakdown of compliance for

safeguarding training courses as of June 2018 at trust level for medical staff in medicine is

shown below:

Name of course

Staff

trained

Eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)







Staff we spoke with explained they had access to a dedicated safeguarding team and could

show us how they contacted them. Staff could access safeguarding information and advice

through the trust’s intranet pages.

The hospital had arrangements to safeguard adults and children from abuse and neglect

that reflected relevant legislation and local requirements. Staff understood their

responsibilities and adhered to them. For example, nurses explained how they reviewed patients’

social circumstances on admission and staff would look out for signs of self-neglect. Staff we

spoke with knew how to report concerns about disrespectful, discriminatory or abusive behaviours

through the trusts’ electronic reporting system.

The trust had processes to safeguard women or children with, or at risk of, Female Genital

Mutilation (FGM). Staff explained safeguarding training included training on this subject, and how

they would escalate concerns to either the senior sister in charge, or straight to the safeguarding

team for advice.

Staff knew how to ensure patients assessed as at risk of suicide or self-harm and could make

referrals to the mental health liaison team if needed.

At Cheltenham General Hospital the 90% target was met for three of the four

safeguarding training modules for which qualified nursing staff in medicine were eligible.

A breakdown of compliance for safeguarding training courses as of June 2018 for qualified

nursing staff in the medicine division at Cheltenham General Hospital is shown below:

Name of course

Staff

trained

Eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)



Safeguarding Adults (Level 1) 143 159 90% 90% Yes


At Cheltenham General Hospital the 90% target was met for four of the five safeguarding

training modules for which medical staff in medicine were eligible. A breakdown of

compliance for safeguarding training courses as of June 2018 for medical staff in the medicine

division at Cheltenham General Hospital is shown below:

Name of course

Staff

trained

Eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)






At Gloucestershire Royal Hospital 90% target was met for one of the four safeguarding

training modules for which qualified nursing staff in medicine were eligible. A breakdown

of compliance for safeguarding training courses as of June 2018 for qualified nursing staff in the

medicine at Gloucestershire Royal Hospital is shown below:

Name of course

Staff

trained

Eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)






At Gloucestershire Royal Hospital the 90% target was met for none of the five

safeguarding training modules for which medical staff in medicine were eligible. A

breakdown of compliance for safeguarding training courses as of June 2018 for medical staff in

the medicine department at Gloucestershire Royal Hospital is shown below:

Name of course

Staff

trained

Eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)







Staff identified adults and children at risk abuse or harm and worked in partnership with

other agencies to ensure they were protected. Staff were confident to challenge decisions

around patient safeguarding. For example, on stroke wards at Gloucestershire Royal Hospital staff

told us about an incident they raised with the local authority. The local authority felt the incident

had not met the threshold for a safeguarding concern. However, staff told us as they continued to

have concerns about the patient and asked for a review of the decision.


The service did not control some infection risks consistently well. Hospital acquired infection

rates for some bacteraemia’s were already above annual targets and clostridium difficile infections

had been under-reported.

Trust level data – medicine division

The medicine division collected data on the numbers of hospital acquired infections. Data

showed between April and August 2018 there were:

15 reported cases of Clostridium difficile (C. difficile), against a yearly target of 36.

12 reported cases of methicillin-sensitive staphylococcus aureus (MSSA) bacteraemia.

There was no yearly target for this infection.

One reported cases of MRSA bacteraemia, against a yearly target of zero.

One case of pseudomonas aeruginosa bacteraemia, against a yearly target of zero.

Not all staff were performing hand hygiene when audited against standards. Monthly hand

hygiene audits showed nursing staff compliance, across both sites, between April and September

2018, ranged from 88% to 97% and doctor compliance ranged from 73% to 90%.

There was a good standard of ward cleaning. Wards audited the quality of cleaning on a

weekly basis. Data showed most wards scored over the trust standard of 90% for high-risk areas.


The medicine team leadership monitored infection control at monthly quality board

meetings. The trust was reviewing an increased incidence of C. difficile as a serious incident. The

investigation found the trust was under-reporting C. difficile cases (56 were reported but there

were 72 cases). The trust had an action plan to reduce the incidence of C. difficile across both

hospital sites. Actions included nursing staff ensuring patients cleaned their hands before

mealtimes and completing investigations of each incidence of C. difficile. The trust had set up a

steering group to monitor the progress against the action plan every month. Some ward areas had

infection control action plans. For example, we saw ward 4B had an action plan for prevention of

further post 48-hour C. difficile cases.

The infection control lead nurse was working to improve antibiotic prescribing to reduce

infection rates, as some antibiotics can increase the risk of hospital-acquired infections.

For example, the trust had changed clinical pathways for abdominal pain and some respiratory

conditions, so a different type of antibiotic was prescribed to help combat infections.

The trust encouraged staff to have flu vaccinations to prevent the spread of the infection.

At the time of the inspection in October 2018 the trusts flu vaccination was in progress.

Cheltenham General Hospital and Gloucestershire Royal Hospital

Cleaning staff maintained standards of cleanliness and hygiene but systems to prevent and

protect people from healthcare associated infections were not always reliable. We found

some ward areas, including corridors, were cluttered and untidy making them hard to clean. For

example, on Snowshill ward, lots of equipment was stored in the corridor due to a lack of storage

space on the ward. This made cleaning more difficult for staff.

Staff we saw followed uniform and hand-hygiene policies. Staff wore clean uniforms, were

‘bare below the elbow’ in clinical areas and had their hair tied up if applicable. We observed staff

following the trust policy on the use of hand gel when entering wards. Ward areas we visited were

visibly clean.

Staff cleaned equipment between use. During our last inspection, we found there was no

effective system for informing staff when commodes were clean. We checked commodes on every

ward we visited on both sites and found all commodes were labelled with a green sticker, showing

it was cleaned and prepared for use.

While staff on wards could not always describe to us the frequency or method of curtain

washing, arrangements for the laundering of curtains was in line with the trust’s ‘curtain

procedure policy’. The trust kept records centrally in the linen department in relation to the

frequency of changing of fabric curtains.

There were infection prevention and control protocols in use for the protection of other

patients and visitors to wards. Nurses screened patients for infections on admission. Staff

placed patients with an infection, or who were at risk of contracting an infection, in side rooms

when possible. Side rooms for infectious patients were marked clearly and staff entering these

rooms wore aprons and gloves which they disposed of before leaving the room. We saw staff

challenging people if they entered the isolated area without personal protective equipment.

The 2018 Patient Led Assessment of the Care Environment (PLACE) score showed

Cheltenham General Hospital achieved 97.5% for cleanliness, similar to the national

average score 98.5%. The PLACE score for Gloucestershire Royal Hospital was 96.3% for

cleanliness, slightly lower than the national average score 98.5%. Please note, however, PLACE

scores are for the whole hospital site not just the medical care service.


At the last inspection we found staff did not always follow legislation on the Control of

Substances Hazardous to Health (COSHH). We found this had not improved at Gloucestershire

Royal Hospital. For example, on ward 9B we saw containers of chlorine tablets in an unlocked

cupboard in a sluice room that was not locked. Following the inspection, the trust produced an

action plan to address this issue with actions such as ensuring all cleaning cupboards are

lockable.

The endoscopy department followed processes to decontaminate equipment after each

procedure. At Gloucestershire Royal Hospital in the purpose-built endoscopy unit, there was a

clear separation of the clean and dirty utility areas. There were four autoclaves for sterilising the

equipment and staff wore personal protective equipment such as apron, gloves and a face shield.

The unit had procedures for safe practice if patients were admitted with a known transmittable

infection such as tuberculosis. Staff would ensure these patients were seen at the end of the day

and the room and associated equipment was deep cleaned. This met the standards in the Health

Technical Memorandum 01-06: decontamination of flexible endoscopes. Staff placed used

equipment in trays lined with red bags to show they needed cleaning.



The design, maintenance and use of facilities kept people safe, although some checks and

storage needed to be improved. Some ward areas were cluttered. For example, at Cheltenham

General Hospital, bay D of the acute medical unit had office cabinets and a photocopier along one

wall next to inpatient beds. On Snowshill ward, corridors were cluttered with equipment due to a

lack of storage space.

Staff had access to emergency resuscitation equipment on all wards, but some was not

always checked as required to ensure it was safe and ready for use. Emergency resuscitation

equipment was stored in trolleys with tamper-evident drawers so emergency medicines and

equipment were secure. We found staff did not always complete daily checks of resuscitation

equipment. For example, at Cheltenham General Hospital, on Ryeworth ward, we found gaps in

records for daily checks. At Gloucestershire Royal Hospital, on ward 8A, we found 12 dates

through July and September 2018 where the daily defibrillator check had not taken place. On ward

6A we found nine consecutive days in September 2018 where the daily check had not taken place.

We raised this with staff on the wards and staff told us the trust policy stated defibrillators were to

be checked daily and the sealed emergency equipment trolley was to be checked weekly.

Following the inspection, the trust produced an action plan to improve compliance with the policy.

On the acute medical unit at Cheltenham General Hospital, we checked the resuscitation

equipment and found the defibrillator was beyond the service date of Sep 2018. Daily checks

had taken place after this, but staff had not identified the defibrillator was overdue for servicing.

When we raised this with senior staff, action was taken, and the maintenance team were called to

arrange for an urgent replacement.

The trust had systems for ensuring equipment was well-maintained. Apart from the item

above, other items of equipment we checked on wards had been serviced and were within date for

servicing. Store rooms were available on each ward. We checked random samples of consumable

items such as syringes and dressings and found these to be within the advised use by dates.

Decontamination equipment in the endoscopy department was calibrated every week by the

manufacturer.


Staff followed procedures for managing, storing and disposing of waste safely. We saw staff

separated waste appropriately.

Equipment for blood sugar monitoring was standardised across the trust. During the last

inspection we found not all staff had training on use of a new blood sugar monitoring machine.

This had improved. Nurses had training in use of the blood sugar monitoring equipment and

calibrated the machines every day, in line with manufacturer’s guidance.

There was enough room the chairs and one trolley in the medical day unit at

Gloucestershire Royal Hospital. We found this had improved. During the last inspection, we

found the environment was cramped and patients had limited space.

The design of ward areas kept patients safe. However, at Gloucestershire Royal Hospital, the

design of the acute medical initial assessment area (AMIA) and ambulatory emergency care unit

(AEC) made it difficult for nurses to observe all patients and the unit had no dedicated area to care

for a patient if they became critically unwell. We reviewed the standard operating procedure for the

AMIA and AEC and there was a clear process for deteriorating patients to be directly admitted to

the acute medical unit or the emergency department.

Some maintenance work was in progress at the time of our inspection and it was being

managed well. For example, at Gloucestershire Royal Hospital, on the cardiac ward, a large

section of the floor was taken up due to a water leak. It was cordoned off to prevent people from

tripping on the edges. Staff explained the source of the leak had been found and a new floor

ordered which was due to be fitted in the weeks after our inspection.



Staff consistently completed and updated risk assessments for each patient. However, staff

did not always take appropriate actions when they identified deteriorating patients.

Staff managed risks positively and acted to reduce risk to patients. For example, nurses

placed patients at the highest risk of falls in beds closest to the nurse’s station, so they could be

observed more easily. Some areas had high dependency bays for the most unwell patients. For

example, at Gloucestershire Hospital, 8B (respiratory ward) had a ten-bed high acuity area.

Nursing staff completed comprehensive risk assessments for patients on admission in line

with national guidance. Patient records we reviewed included various assessments such as falls

risk assessments, pressure ulcer risk assessments, and malnutrition risk assessments.

Audits of patient notes by the trust showed improvements were needed in assessing and

escalating the risks of deteriorating patients. The trust audited the quality of completion of

NEWS2 charts. We reviewed the NEWS2 audits for September 2018 and found poor compliance

with the audits across most wards on both hospital sites. Staff received feedback on actions

needed to improve where performance was poor, and encouragement given where compliance

was good.

Staff in the medicine division used the revised national early warning score (NEWS2) to

identify deteriorating patients and respond appropriately to medical emergencies. The

medical division audited records and risks assessments. The completion and accuracy of NEWS2

was audited monthly by review of a random sample of five records on each ward. Feedback was

provided to the ward on compliance with NEWS2. We saw examples of audits completed for both

hospital sites with actions and feedback to staff where performance needed to improve. For


example, actions included reminders to staff to improve the completeness and accuracy of

observation recording.

Staff understood how to respond to deteriorating patients, including those with suspected

sepsis. Nurses continually monitored and assessed patients admitted with suspected or

confirmed sepsis using the national early warning system (NEWS2), in line with the trust sepsis

policy. We saw evidence of the sepsis care bundle in use. For example, on the oncology wards at

Cheltenham General Hospital, staff followed the sepsis six pathway, and showed us a patient

group direction (authority to administer certain medicines) which allowed nurses to administer a

specific antibiotic stored on the ward. Staff explained how neutropenic patients (those more

susceptible to infections) needed medicines to be administered quickly because of their weakened

immunity. We saw two completed sepsis care plans. Patients showing signs of sepsis were

recognised and reviewed with appropriate treatment started promptly and according to best

practice.

Doctors we spoke with, at both sites, did not have any concerns about the nursing teams’

ability to recognise deteriorating patients and respond. Staff had access to an acute care

response team when they had concerns about patients, and staff we spoke with were positive

about the responsiveness of the team.

While staff understanding of responding to deteriorating patients was good, staff did not

always complete and escalate NEWS2 charts appropriately at Cheltenham General

Hospital. On the coronary care unit at Cheltenham General Hospital we reviewed a NEWS2 chart

that was not completed correctly. It did not show any documented evidence that the elevated

NEWS2 score had been escalated or any actions had been taken. At Gloucestershire Royal

Hospital, nurses completed and escalated NEWS2 charts appropriately. We reviewed a total of

nine NEWS2 charts across wards 6A, 6B, 7A and 8A which had all been completed correctly.

They showed appropriate escalation where the score required this and medical staff had reviewed

the patients promptly.

The trust measured its performance against a ‘commissioning for quality and innovation’

target (CQUIN) for reducing the impact of serious infections (antimicrobial resistance and

sepsis). The trust audited the proportion of sepsis patients who received antibiotics within one

hour and the percentage of patients screened for sepsis using NEWS2. Data showed compliance

for inpatients screened for sepsis had improved from 20% in May 2018, to 90% in June and 100%

in July and August 2018. NHS England included the trust in a national report as an example of a

‘top performer’ for improving safe management of sepsis.

Staff mostly completed assessments of cannulas (a small plastic tube inserted into a vein)

used for intravenous medicines or drips but not at all times. Staff used a tool (visual infusion

phlebitis (VIP) score) which needed to be completed daily as invasive devices can increase the

risk of infection. We looked at nine records on wards at Gloucestershire Royal Hospital and found

this was not being consistently done in two sets of records.

Staff had training to enable them to respond to patient risks appropriately. For example, the

trust provided clinical and nursing staff with access to an e-learning package on use of the sepsis

six bundle. The training was not mandatory, but all new doctors were expected to complete it as

part of their induction.

The trust had worked to improve the quality of handover from the emergency department to

the acute medical unit by reviewing the safety and effectiveness of the process. The trust

planned to continue this work and review the process for handover of patients from acute medical

units to medical wards. The process at the time of inspection involved a clinical conversation and a


standardised approach to use of NEWS2. If patients were medically unstable they would be

accompanied by a healthcare assistant or nurse from the emergency department to the acute

medical unit.

Nursing staff had access to medical staff to review patients whose condition had changed.

The trust had processes to ensure consultants or senior medical clinicians reviewed patients

during daytime hours Monday to Friday. The different specialities had consultant cover during the

week from 8am to 8pm. There were daily board rounds on the wards at 8:30am. There were

attended by doctors, nurses, physiotherapists and discharge coordinators. Each patient was

discussed to identify actions to support the treatment, care and discharge planning. The board

round was followed by a consultant ward round and a second ‘board round’ (staff met to discuss

patients’ condition and treatment plan away from the bedside). This was followed by a further

round at 3:30pm to ensure staff had achieved all actions. Across both hospital sites, unplanned

medical admissions were reviewed by a consultant within 12 hours of admission in all the records

we reviewed. Patients were reassessed at daily consultant ward rounds from Monday to Friday. At

weekends, ward rounds junior doctors carried out by who contacted consultants if patients had

deteriorated and they needed advice.

Staff on acute assessment units at both hospitals had an awareness of the risks associated

with patients assessed as at risk of suicide. Nurses explained they would place these patients

in observable bays and never alone in a side room. Staffing for one to one enhanced care would

be arranged to ensure the patient was constantly monitored. Nursing staff on acute medical units

and older people’s care wards had received training in delivering enhanced one to one care to

patients requiring a high level of observation.

Staff knew how to access the trust violence and aggression team if necessary. Staff

described using de-escalation technique to calm a patient exhibiting aggressive behaviour and

calling security and the violence and aggression team when necessary.

Nurse staffing

Cheltenham General Hospital and Gloucestershire Hospital

The service had enough nursing staff with the right qualifications, skills training and

experience to keep people safe from avoidable harm and to provide the right care and

treatment most of the time. At the last inspection, the service did not assess or record the needs

(acuity) of patients on each shift on each ward to ensure safe staffing levels. We found this had

improved. Ward managers assessed staffing levels, acuity and dependence of patients regularly

throughout the day and information was provided to matrons and senior managers. Numbers of

planned and actual staffing levels were displayed openly on wards for patients and visitors to see.

Ward managers were aware of the escalation process if nursing or healthcare assistant

shifts could not be filled due to unplanned staff absence. Staff were moved to areas in greater

need of staff if necessary and ward managers kept a record of how often this happened. Staff told

us the trust had recently piloted a new acuity tool but at the time of our inspection this had not

been implemented.

Most wards we visited were staffed as planned and staffing reports showed that wards

were usually staffed as planned. Ward managers reviewed staffing every day and sent safer

staffing reports to matrons every month. The reports included the number of registered and

unregistered nursing staff, the number of shifts that were not covered, and details of any patient

safety incidents. We reviewed staffing reports from Cheltenham General Hospital for the last three

months for Avening (respiratory) and Woodmancote and Ryeworth (elderly care wards) and found


that the average fill rate for registered nurses during the day was consistently above 90%. The fill

rate for registered nurses at night was below slightly 90% in July, August and September 2018.

We reviewed staffing reports from Gloucestershire Royal Hospital for the last three

months for wards 4A and 4B (elderly care wards) and found that the average fill rate for

registered nurses during the day was consistently above 90%. The fill rate for registered

nurses during the day was slightly below 90% in July and on 4A and slightly below 90% in August

was below slightly 90% in July, August and September 2018. At night on ward 4A in August 2018

the fill rate went down to 75% and was 74% in September 2018.

Most wards we visited at Gloucestershire Royal Hospital had nurse staffing vacancies for

registered nurses, but this was managed safely through use of bank and agency staff. The

service reduced the risk of staff vacancies by using regular agency and hospital bank staff. The

impact of vacancies was a high workload for staff, but the staffing levels were reviewed regularly

to ensure patient safety.

Staff on ward 7B (renal) at Gloucestershire Royal Hospital said nursing shifts were not

always covered by agency staff as they were a specialist area. We reviewed staffing reports

for the past three months and found that that the ward was frequently one registered nurse down

during the late shift (13 times in September, 28 times in August and 12 times in July 2017). The

risk was reduced by specialist renal nurses from renal outpatients coming to support the ward. The

ward had recently recruited nurses to meet its establishment numbers, so this would improve the

staffing levels.

Arrangements for handovers and shift changes ensured people were kept safe. Nursing

handovers included a safety briefing with key information, such as falls risks and resuscitation

status, about all patients on the ward. This was followed by a more detailed handover between

nurses in the individual bays. Senior nurses told us they used the safety briefing as an opportunity

to spread trust-wide messages, look at staffing levels, and feedback from incidents or audits. For

example, we observed nursing handover on Lilleybrook (oncology) ward at Cheltenham General

Hospital and ward 6B at Gloucestershire Royal Hospital. Here we heard detailed discussions

between staff about each individual patient they were responsible for.

The service was reviewing staffing rotas to improve patient safety and staff wellbeing. At

Cheltenham General Hospital, elderly care wards, Woodmancote and Ryeworth, were creating

new rotas so staff would not work 12-hour long shifts and these would be reduced. Senior nurses

told us staff were happy with the proposed changes to the rotas.

There was a high number of healthcare assistant vacancies across elderly care wards, but

the trust was in the process of recruitment. At the time of inspection, on Woodmancote, there

were three registered nurse vacancies and 11 healthcare assistant WTE vacancies. A senior

nurse told us there had been a trust-wide recruitment drive to recruit healthcare assistants and 50

had been recruited. As it was easier to recruit to healthcare assistant posts in Gloucestershire

Royal Hospital , there was a free shuttle bus to allow staff from Gloucester to travel to shifts in

Cheltenham General Hospital.

The service had arrangements for using bank, agency or locum staff which kept patients

safe. On oncology wards, senior staff explained if agency staff were used, they would be regular

staff to ensure continuity of care for patients. Agency staff would only be expected to undertake

general nursing duties due to the specialist nature of the wards.

When patients needed one to one enhanced care, bank or agency staff could be booked to

so the numbers of staff on duty were not reduced. However, some staff we spoke with said

requests for extra staff to support patients needing enhanced care were not always filled.


The service considered the impact on the safety of patients when carrying out changes to

the service or the staff. For example, at Gloucestershire Royal Hospital, as part of the stroke

services reconfiguration, although bed numbers at the hospital were being reduced, therapy staff

numbers were staying the same.


The trust nursing workforce had vacancy, turnover and sickness rates similar to national

levels. The trust has reported their staffing numbers below for March and May 2018 for medicine.

Across both hospitals, a fill rate of 76.5% was reported for qualified nursing staff in March 2018

and an improved fill rate of 93% was reported for May 2018. A breakdown by site can be found

below.

March 2018 May 2018

Location

Actual

staff –

WTE in

month

Planned

staff –

WTE

Fill Rate

Actual

staff –

WTE

in

month

Planned

staff –

WTE

Fill Rate

Gloucestershire Royal Hospital 196.5 280.9 70.0% 207.3 233.8 88.7%

Cheltenham General Hospital 135.1 152.4 88.6% 144.8 144.9 99.9%

(Source: Routine Provider Information Request (RPIR) –Total staffing tab)

Vacancy rates

Nursing vacancies were close to zero at Cheltenham General Hospital but at 11.3% at

Gloucestershire Royal Hospital.

As of May 2018, the trust reported a vacancy rate of 6.3% in medicine:

Cheltenham General Hospital medicine department: 0.1%

Gloucestershire Royal Hospital medicine department: 11.3%

The trust did not report an overall target vacancy rate.

(Source: Routine Provider Information Request (RPIR) – Vacancy tab)

Turnover rates

Turnover of nursing staff was below the trust target at Cheltenham General Hospital but above

the target at Gloucestershire Royal Hospital.

From June 2017 to May 2018, the trust reported a turnover rate of 12.1% in medicine:



This is compared to the trust’s overall target turnover rate of 11%.

(Source: Routine Provider Information Request (RPIR) – Turnover tab)

Sickness rates

Sickness rates for nursing staff were lower (better) than the national average of 4.5% for NHS

nursing staff.


From June 2017 to May 2018, the trust reported a sickness rate of 3.8% in medicine:



This is compared to the trust’s overall target sickness rate of 3.5%.

(Source: Routine Provider Information Request (RPIR) – Sickness tab)


Medical staffing


The service had enough medical staff with the right qualifications, skills training and experience to keep people safe from avoidable harm and to provide the right care and treatment most of the time. Medical staffing and cover arrangements kept people safe. Doctors we spoke with told us the wards were well-staffed. However, doctors from both hospital sites raised concerns about the arrangements for medical cover overnight at Gloucestershire Royal Hospital. Medical staff told us the overnight medical workload increased when the emergency department closed at Cheltenham General Hospital overnight, as the extra activity was directed to Gloucestershire Royal Hospital. The trust had acted to improve middle grade medical cover. It had been recognised how junior doctors covering both hospital sites put pressure on the overnight team. In response to this, the trust had successfully recruited to clinical fellow roles (ST3) level by working from 5pm to 9pm in the evening Monday to Thursday.

Medical staff on elderly care wards at Cheltenham General Hospital, Woodmancote and Ryeworth worked together to cover short term unplanned absence. The wards were usually staffed by two junior doctors and a consultant.

There was satisfactory medical staffing cover to meet the needs of patients. At both

hospitals, a consultant was available at all times for the acute medical services. For example, the

acute medical initial assessment area (AMIA) and the ambulatory emergency care unit (AEC), at

Gloucestershire Royal Hospital, was staffed by one junior doctor, a consultant and two advanced

nurse practitioners. Nursing staff told us they did not have difficulties gaining advice from a doctor

or consultant out of normal working hours. Wards we visited had regular consultant-led board

rounds. For example, ward 9B had a full consultant led board round three times a week. A junior

doctor we spoke with felt the ward was well-staffed from a medical perspective.

Nursing staff told us they did not have difficulties gaining advice from a doctor or

consultant out of normal working hours. Doctors said consultants were very responsive. For

example, we were told of a rota error which had resulted in no medical consultant cover. As a

result, the hospital had put out a call for support to the medical consultant team which resulted in

the on-call medical consultant and another consultant coming in to cover the shift.

Junior doctors we spoke with across both sites felt well supported. During the day,

consultants worked in speciality areas supported by ward-based junior doctors. Consultants and

junior doctors supported trainee doctors (F1/F2 foundation doctors).


There were low levels of absence, turnover and vacancies among the medical team. The

trust has reported their staffing numbers below for March and May 2018 for medicine. Across the

trust, a fill rate of 95.1% was reported for medical and dental staff in March 2018 and a fill rate of

92.7% was reported for May 2018.

A breakdown by site can be found below.

March 2018 May 2018


Location

Actual

staff –

WTE in

month

Planned

staff –

WTE

Fill Rate

Actual

staff –

WTE

in

month

Planned

staff –

WTE

Fill Rate



(Source: Routine Provider Information Request (RPIR) –Total staffing tab)

Vacancy rates

As of May 2018, the trust reported a vacancy rate of 7.8% in medicine:




(Source: Routine Provider Information Request (RPIR) – Vacancy tab)

Turnover rates

Medical staff turnover at both hospitals was low.

From June 2017 to May 2018, the trust reported a turnover rate of 1.6% in medicine:

Cheltenham General Hospital medicine department: 0%


This is compared to the trust’s overall target turnover rate of 11.0%.

(Source: Routine Provider Information Request (RPIR) – Turnover tab)

Sickness rates

Medical staff sickness rates across both sites were low.

From June 2017 to May 2018, the trust reported a sickness rate of 0.5% in medicine:



This is compared to the trust’s overall target sickness rate of 3.5%

(Source: Routine Provider Information Request (RPIR) – Sickness tab)

Medical staffing skill mix

The staffing skill mix compared well with the England average. In May 2018, the proportion

of consultant staff reported to be working at the trust was about the same as the England

average and the proportion of trainee (foundation year 1-2) staff was the same.


Staffing skill mix for the 254 whole-time-equivalent staff working in medicine at


This

Trust

England

average

Consultant 41% 43%

Middle career^ 8% 6%

Registrar group~ 29% 28%

Trainee* 22% 22%

^ Middle Career = At least 3 years at SHO or a higher grade within their chosen specialty

~ Registrar Group = Specialist Registrar (StR) 1-6

* Trainee = Foundation Year 1-2

Source: NHS Digital - Workforce Statistics - Medical (01/05/2018 - 31/05/2018)

Records


Staff kept detailed records of patients’ care and treatment. Records were clear, up to date

and available to all staff providing care. The service managed individual care records,

including clinical data, in a way that kept people safe. Medical and nursing notes were paper

records and test results were on electronic records. Staff stored patient medical records securely

on wards in trolleys that locked with a keypad code to maintain confidentiality. Nursing care

records were kept at the end of a patient’s bed.

Staff had access to all the information they needed to deliver safe care and treatment. Staff

accessed electronic information about patients on computers which staff were required to lock

when not supervised to keep patient information secure. However, we saw one member of staff

at Gloucestershire Royal Hospital walk away from a computer screen without locking it. They

returned to the computer a minute later, however the computer was located facing outwards onto

the main corridor through the ward and patient information was visible.

We reviewed six sets of clinical records at Cheltenham General Hospital and 12 at

Gloucestershire Royal Hospital and saw most essential documentation, such as risk

assessments, observation charts and fluid monitoring charts were completed. Staff wrote

patient-centred care plans to meet the needs of the patient. In addition, essential documentation

we saw included bed rail care plans, pressure ulcer care plans and alcohol withdrawal

management plans.

We reviewed the records of six medical patients who were placed on other non-medical

wards due to the lack of available beds in the most suitable ward. The records showed the

medical team responsible for the care and treatment of the patient had visited the outlying ward

regularly to review the patient and a treatment plan was written clearly.


Senior nurses completed documentation audits to monitor the quality of nursing records.

For example, at Gloucestershire Royal Hospital the sister on ward 9B showed us how they

completed documentation audits every month. The documentation audit included a review of

nursing care plans, national early warning score charts, patient turns, and malnutrition

assessments. The sister did a random sample of six patients identified and increased the sample

to 12 if there were problems. Staff received the audit results through email.

Medicines


Staff managed medicines safely most of the time but did not always follow best practice when storing medicines. Staff stored medicines securely in locked cabinets and fridges in locked clinical treatment rooms. They were only accessible by clinical staff. Extra stock was stored in locked cupboards inside treatment rooms which were locked on most wards. The treatment room on the acute assessment unit did not have a door but the ward manager told us a replacement door was on order and the medicines were stored in a locked cupboard.

Staff recorded patients’ allergies clearly on drug charts. Allergies were clearly documented in the 12 prescribing documents we looked at. Staff on the oncology ward at Cheltenham General Hospital showed us they used a red wrist band for patients to identify allergies and documented when patients told them they had an allergy in notes.

Checking and storage of medicines did not always keep people safe. For example, at Cheltenham General Hospital, on Rendcomb (oncology) ward, staff did not complete daily refrigerator temperature checks consistently. Staff did not act when checks showed the temperature was too high or too low. In June 2018 there were 20 days when staff recorded maximum temperatures up to 4.5 degrees outside of the safe recommended maximum temperature. On these days, there was no evidence recorded of any escalation or actions taken to address increased temperatures. Actions should have included contact with pharmacy, stock rotation or re-checking temperatures, in line with trust policy. On the same ward we found three days in June 2018 where the fridge used to store chemotherapy medicines did not have any actions recorded when the temperature had exceeded the recommended range. We raised these issues with the ward manager who took immediate action to ensure all medicines stored were safe for use. Following the inspection, the trust produced an action plan to improve compliance the medicines management policy. Furthermore, on the medical day unit at Gloucestershire Royal Hospital, the fridge temperatures had risen outside of recommended range on a number of occasions and there was no recorded information about action taken to ensure the safety of the medicines.

Most liquid medicines were stored safely. However, there was an example of staff not following the trust’s policy with liquid medicines as the date of opening a bottle was not recorded. Liquid medicines should have the date of opening written on the label on the bottle to ensure the contents are used within the expiry from opening date. On Woodmancote (elderly care) ward, we found opened bottles of a liquid pain relief medicine where staff had not recorded the date of opening. We raised this with the nurse in charge at the time of inspection and the next day new ‘date opened’ labels had been printed and a reminder given to staff.

Oxygen cylinders were not always stored securely on the wards. We saw loose oxygen cylinders on the floor on Ryeworth ward at Cheltenham General Hospital and at Gloucestershire Hospital on ward 9B and 8B. Medical gas cylinders should be stored securely in an upright position. They should not be free standing as this is a trip hazard to staff and patients.

Staff managed controlled drugs in line with trust policy, most of the time. At Cheltenham General Hospital, on Woodmancote ward, we saw controlled drugs balance checks were completed twice a day by two nurses. We completed a random balance check and physical stock matched the register. We carried out spot checks on controlled drugs on Rendcomb ward at Cheltenham General Hospital and found these corresponded with records. We carried out spot checks on controlled drugs on ward 8A at Gloucestershire Royal Hospital found these


corresponded with the records. Extra stock was held in locked cupboards inside treatment rooms. However, on Woodmancote (elderly care) ward, at Cheltenham General Hospital, some patients’ own controlled drugs had been left on the ward after the patient had been discharged, which was not in line with the trust policy.

Staff prescribed, administered or supplied to people in line with the relevant legislation, current national guidance or trust policy. However, some paperwork was out of date. For example, at Gloucestershire Royal Hospital, on ward 6A, we found a folder on the nurses’ station which contained a selection of patient group directions (authority to administer certain medicines), which were out of date. Three had expired in February 2018, two in April 2018 and two in June 2018. Five were due to expire in October 2018.

Nurses administered medicines safely. Nurses wore red tabards to show they were undertaking a medicine round and should not be disturbed, where possible. Nurses checked the patient’s identity before administering medicines. For example, we saw a nurse on ward 7A (gastroenterology) checking the patient’s name, date of birth and wristband before administering a pain relief medication. When people had pain relief patches applied, the site of application was recorded. Nurses recorded when they removed or replaced the patch.

Doctors reviewed medicines appropriately. We saw staff completed and reviewed venous thromboembolism assessments, and took appropriate action such as prescribing injections, tablets or compression stockings. Pharmacists reviewed patient antibiotics periodically in line with the trust’s antibiotic stewardship policy.

Patients received specific advice about their medicines in line with current national guidance and trust policy. For example, we saw a nurse on the coronary care unit at Gloucestershire Royal Hospital sitting with a patient, clearly explaining what medicines they had been given to take home, the doses, and why they had to take them. The patient had time to respond and ask questions, and we saw the nurse checking the patient had understood what had been said to them.

Incidents


Staff managed safety incidents well. Staff understood their responsibilities to raise their

concerns and report patient safety incidents through the electronic reporting system. For example,

staff told us they reported incidents relating to patients whose behaviour was challenging to

manage, and patients who suffered falls. There was a good incident reporting culture and senior

staff encouraged teams to complete electronic incident reports.

We saw evidence in ward meeting minutes of lessons identified from incident, and

improvements made when things went wrong. For example, on the cardiac ward at

Cheltenham General Hospital, staff described how there had been changes to treatment plans to

avoid confusion about stopping medicines, or not doing so, when they gave patients certain side

effects.

Senior nurses discussed learning from incidents with all staff at ward team meetings. For

example, at Gloucestershire Royal Hospital, the minutes of the August 2018 ward meeting on 9B

included lessons learnt from a recent patient fall with reminders to staff to complete falls care

plans. Medication errors were included, for example, in the meeting minutes for ward 7A for July

2018 at Gloucestershire Royal Hospital.

There was a positive incident reporting culture. Staff at Cheltenham General Hospital told us

they were regularly encouraged to use the electronic incident reporting system to report success

and good incidents alongside adverse incidents and near misses. Staff had affectionately renamed

the system ‘Greatix’.

Never events


From August 2017 to July 2018, the trust reported one incident classified as a never event

for medicine. This was a medication incident meeting SI criteria. Never events are serious

patient safety incidents that should not happen if healthcare providers follow national guidance on

how to prevent them. Each never event has the potential to cause serious patient harm or death,

but neither need have happened for an incident to be a Never Event.

(Source: Strategic Executive Information System (STEIS))

Breakdown of serious incidents reported to STEIS

In accordance with the Serious Incident Framework 2015, the trust reported 14 serious incidents (SIs) in medicine which met the reporting criteria set by NHS England from August 2017 to July 2018. Of these, the most common types of incident reported are shown in the graph below:


The trust monitored patient safety information from a range of sources. We reviewed the

medical division performance dashboard for August 2018 and saw the following data was

included: never events, serious incidents, open incidents, medication incidents, violence and

aggression incidents, infection control incidents, and pressure ulcer incidents. The number of

minor incidents senior nurses had reviewed and closed was also included in the dashboard. The

data was broken down to site and ward level, so the service could identify trends.

We reviewed the minutes for the last three quality board meetings and found serious

incidents and the serious incident scoping panel were standard agenda items. The serious

incident scoping panel was a monthly meeting where senior medical staff reviewed incidents to

check if they met the criteria to be graded as a serious incident and begin the investigation

process. Trends in incident reporting were discussed at the quality board. For example,

discussions were held relating to an increase in pressure ulcers.

The trust applied duty of candour appropriately. Duty of candour is a regulatory duty that

relates to openness and transparency and requires providers of health and social care services to

notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide

reasonable support to that person. The trust held Duty of candour meetings every month to review

ward actions following the completion of investigations.

We reviewed root cause analysis reports for a sample of three serious incidents. We found

the incidents were investigated thoroughly and learning identified. We saw evidence of Duty of

candour being followed in the three incidents we reviewed. The patient safety investigation team

wrote to patient and their next of kin to ask if they wanted to contribute to the investigation and

receive a copy of the final investigation report.


At the last inspection we found the trust did not have a systematic approach to mortality

and morbidity (M&M) meetings. We found this had improved. The service used M&M reviews as

a learning opportunity to improve the service. They were held at speciality level. A doctor we

spoke with told us M&M reviews happened once a week in the care of the elderly team. The

meetings were led by two junior doctors and there was an opportunity to discuss issues relating to

patient care. We reviewed the M&M meeting minutes for vascular, dermatology, cardiology and

gastroenterology specialities and found the meetings were well-attended by doctors and

consultants. Medical staff discussed individual cases, Duty of candour, and learning points

identified where applicable.

Safety thermometer


Trust level data Data from the NHS patient safety thermometer showed the trust reported 51 new pressure

ulcers, 22 falls with harm and 19 new urinary tract infections in patients with a catheter

from July 2017 to July 2018 for medical services. The NHS safety thermometer is used to

record the prevalence of patient harms and to provide immediate information and analysis for

frontline teams to monitor their performance in delivering harm free care. Measurement at the

frontline is intended to focus attention on patient harms and their elimination. Data collection takes

place one day each month – a suggested date for data collection is given but wards can change

this. Data must be submitted within ten days of suggested data collection date.

Prevalence rate (number of patients per 100 surveyed) of pressure ulcers at Gloucestershire Hospitals NHS Foundation Trust

1

Total Pressure ulcers (51)

2

Total Falls (22)

3

Total CUTIs (19)

1 Pressure ulcers levels 2, 3 and 4 2 Falls with harm levels 3 to 6


3 Catheter acquired urinary tract infection level 3 only

(Source: NHS Digital - Safety Thermometer)

The hospital reported data on patient harm to the NHS Health and Social Care Information

Centre each month. This was nationally collected data providing a snapshot of patient harm on

one specific day each month. This included hospital-acquired (new) pressure ulcers (including only

the two more serious categories of harm) and patient falls with harm.

The service used safety monitoring results well.

The NHS safety thermometer results (reporting harm-free care) were displayed for patients

and the public to see on all wards we visited. The service was focused on patient safety and

reducing patient harm. A tissue viability action plan included an aim to reduce hospital acquired

category two pressure ulcers by 50%. The service aimed to achieve this through improved

education, audits of pressure care bundles, and access to pressure relieving mattresses and

cushions. The service promoted patient safety campaigns such as ‘React to Red’ study days for

healthcare assistants to promote better pressure ulcer prevention work.

On Avening (respiratory) ward at Cheltenham General Hospital, and ward 4B at

Gloucestershire Royal Hospital a recent pilot study called ‘cheers ears’ had managed to

significantly reduce heel and device related pressure ulcers. Staff achieved this using bedside

laminated prompts, heel alert magnets, preventative dressings for patents, and regular monitoring.

The tissue viability team produced and shared findings with other hospitals and had travelled to

other NHS trusts nationwide to present their findings.



Cheltenham General Hospital and Gloucestershire Royal Hospital The service provided care and treatment based on national guidance and evidence of its effectiveness. The service had processes to support the delivery of evidence-based care and treatment. The medicine division had a yearly clinical audit programme to support and monitor the implementation of National Institute for Health and Care Excellence (NICE) guidance. The trust had appointed an audit lead in July 2018 and each medical speciality had an audit lead. The trust was working to align quality improvement and audit programmes in order to make this work more engaging and focused on improving patient care. Audit programmes we reviewed for dermatology, rheumatology and endoscopy included details of: quality improvement projects, participation in national audits, and quality assurance work staff were completing. Medicine division senior leaders discussed audit, clinical improvement and compliance with NICE quality standards at monthly quality board meetings.

Staff delivered care and treatment in line with national evidence-based guidance. The

medical service had clinical policies and patient pathways based on the quality standards for

medical conditions published by the National Institute for Health and Care Excellence (NICE). Staff

had access to clinical policies through the trust intranet. For example, we saw evidence in patient

records that staff followed evidence-based treatment pathways for chest pain, acute kidney injury,

for patients with suspected or confirmed sepsis, and national stroke pathways. At Cheltenham

General Hospital, on Snowshill (gastroenterology ward), we saw staff used the clinical institute

withdrawal assessment – Alcohol (CIWA-A) in line with NICE clinical guideline 100 ‘Alcohol-use

disorders: diagnosis and management of physical complications.’


On the ambulatory emergency care units, at both hospitals, staff followed evidence-based

pathways for asthma, low-risk chest pain and painless jaundice. When patients were

discharged from the service, staff told them how to access further help if their condition

deteriorated. During opening hours, patients could phone the doctor at the ambulatory care unit for

advice after they were discharged from the unit.

Staff kept themselves up to date on changes to clinical guidance. For example, staff on the

coronary care unit described how they implemented updates and changes to evidence-based

practice, most recently around the measurement of troponin levels in some cardiac patients.

Staff carried out endoscopic procedures, such as diagnostic upper gastrointestinal

endoscopy, in line with professional guidance. The endoscopy unit had achieved Joint

Advisory Group (JAG) accreditation. JAG is an external body which carries out a planned review

and inspection of facilities, policies, procedures and equipment against national best practice

standards.

Patients received regular consultant review in line with best practice. Consultants reviewed

patients in the acute medical unit twice daily and this was recorded in patients’ records. Once

transferred from the acute area of the hospital to a general ward, patients were reviewed during a

consultant-delivered ward round at least once every 24 hours, seven days a week (unless it had

been determined this would not affect the patient’s care and treatment). We saw evidence in

records we reviewed that patients’ treatment plans were reviewed by consultants at least once

every 24 hours.

Staff took account of patients mental and physical health needs. Staff handovers included

reference to patients’ psychological and emotional needs. Staff told us mental health would be

discussed if it was part of the patient’s presenting problem or if there was a change in a patient’s

mental state. On the stroke wards at Gloucestershire Royal Hospital, staff could refer patients to

clinical psychologists for extra support. In one discussion we saw, staff discussed a patient where

the psychologists had been able to meet with the patient’s family separately as staff had identified

by staff they were not coping.



Staff gave patients enough food and drink to meet their needs and improve their health.

Staff assessed patients’ nutrition and hydration needs in line with national guidelines but did not

use the tool consistently. Staff used the malnutrition and universal screening tool (MUST) to

identify patients at risk of malnutrition. At Cheltenham General Hospital we reviewed four patient

records and found MUST assessments were completed consistently. However, at Gloucestershire

Royal Hospital we reviewed five patient records and found MUST assessments were not always

completed consistently in four of five records.

Staff could access dietitians to provide support and advice to patients. For example, staff on

the renal ward at Gloucestershire Royal Hospital had access to a specialist dietitian to support the

ongoing healthy lifestyle choices of is renal patients. Staff explained dietary support was crucial for

these patients as certain aspects of diet, such as potassium intake, had to be carefully monitored.

The service met people’s cultural and religious dietary requirements. For example, staff

could access kosher and halal meals for patients.

All wards used a magnet board behind each patient’s bed which had coloured picture

reminders for staff about specific nutrition and hydration needs for the patient. Picture

reminders included: thickened food, enteral tube feeding, nil by mouth and if the patient needed


support from staff to eat and drink. We saw patients who needed support to eat and drink were

served meals on red trays to alert staff to provide support. The trust had an up to date nasogastric

tube feeding policy.

Drinks and refreshments were available to patients in the discharge waiting area at

Gloucestershire Royal Hospital. Staff could arrange a hot meal for patients who were waiting

over lunchtime.

We saw notices for protected mealtimes on the wards and flexible visiting for carers to

come in and support their relatives to eat. Patients could have food late in the evening as staff

had access to sandwiches and snacks.

The patients we spoke with were generally positive about the hospital food. Most patients

felt the portion size and menu choice was more than sufficient, and food was described as

enjoyable. The feedback from patients on the quality of food was below the national average. The

2018 Patient Led Assessment of the Care Environment (PLACE) score showed Cheltenham

General Hospital achieved 84% for the quality of the food, lower than the national average score

of 90%. Gloucestershire Royal Hospital achieved 84% for the quality of the food, also lower than

the national average score 90%. The PLACE score is for the whole hospital site not just the

medicine division.

Pain relief


Staff assessed and monitored patients regularly to see if they were in pain. Staff assessed

and managed patient’s pain effectively. Patients we spoke with across both sites said they had no

concerns about the way their pain was managed. Patients said nurses responded to their requests

for pain relief quickly and nurses asked about pain levels during routine observations.

Staff used appropriate tools to help assess the level of pain in patients who were living with

dementia. Staff on both sites used an adapted Abbey Pain Scale, to assess the pain of patients

who could not communicate verbally about their pain, including patients living with dementia. Staff

observed patients’ facial expressions and body language to measure and assess pain where

patients could not communicate verbally. For example, on stroke wards at Gloucestershire Royal

Hospital, we saw a variety of pain assessment tools in patients’ records. This included an

assessment for rheumatoid arthritis tailored to one patient’s individual needs. The assessment

used simple numerical pain scales to capture past and current pain levels. Staff could access a

specialist pain team to provide additional support to patients in managing their pain.

Competent staff


The service made sure staff were competent for their roles. Staff had specialist training

relevant to the clinical area they worked in. For example, at Cheltenham General Hospital on the

oncology ward, staff undertook a specialist external chemotherapy course to allow them to

administer chemotherapy to patients in their care. The trust fully-funded the cost of the course

which included scenario-based training, formal essays and examinations. All nursing staff had to

complete this course and be signed off as competent against a specialist framework before they

could administer chemotherapy unsupervised. Staff on the oncology wards received one paid

study day per year in addition to their required mandatory training days to do e-learning and

additional study. At Gloucestershire Royal Hospital, nurses on the renal ward had access to renal

courses every year. Nurses could choose to study with a local university or do the course through

e-learning. At the time of the inspection, two nurses were studying the course and four staff were


waiting to go on the renal course. Nurses completing the renal course had one day protected

learning time a week. All renal nurses did a refresher course on peritoneal dialysis every year.

Staff completed competency frameworks relevant to their roles. For example, at

Gloucestershire Royal Hospital, nurses on the respiratory ward (8B) had relevant competencies

including use of chest drains, high flow oxygen therapy, and bilevel positive airway pressure

(BiPAP) machines.

The trust supported new staff well. The trust had a formal induction process for permanent and

agency staff. Staff who had recently joined the trust felt they had a good induction including

corporate and local induction to the ward or unit. Newly qualified nurses we spoke with across

both sites felt well supported. There was a comprehensive preceptorship programme to support

newly qualified nurses. An induction pack for health care assistants working in the discharge

waiting area (DWA) had been introduced and was being used for the first time for a new HCA.

This included information on the criteria for admission to the DWA and their role in collecting

patients from the wards.

There were effective arrangements for supporting and managing staff to deliver effective

care and treatment. For example, on the oncology wards at Cheltenham General Hospital, staff

had access to a practice development team who oversaw all aspects of staff development and

training. This included inductions, mandatory training updates, sharing of best practice and

guidance updates. However, the trust did not have arrangements for formal clinical supervision

planned or recorded for registering nursing staff. Senior nurses we spoke with told us the trust had

trained clinical supervisors which they could access if nurses requested clinical supervision.

Junior medical staff we spoke with felt well supported by consultants. For example, junior

doctors at Cheltenham General Hospital told us consultants took the time to arrange rotas to make

sure junior doctors got enough experience in clinics. Doctors we spoke across both sites had

regular teaching sessions.

Appraisal rates– medicine division

Not all staff had received a yearly appraisal. Appraisal compliance data is shown below:

From July 2017 to June 2018, 74% of staff within medicine care at the trust received an

appraisal compared to a trust target of 90%. The appraisal completion target was met for only

one staff group at the trust and this was support to ST&T staff with 95% of staff with a complete

appraisal for the period July 2017 to June 2018.

Staff group

Individuals

required

Appraisals

completed

Completion

rate Target

Target

met

(Yes/No)

Support to ST&T staff 19 18 95% 90% Yes

Medical & Dental staff - Hospital 83 68 82% 90% No

Qualified nursing & health visiting

staff (Qualified nurses) 389 290 75% 90% No

Qualified Healthcare Scientists 31 23 74% 90% No

Support to doctors and nursing

staff 311 219 70% 90% No


NHS infrastructure support 16 10 63% 90% No

Other Qualified Scientific,

Therapeutic & Technical staff

(Other qualified ST&T)

1 0 0% 90% No

(Source: Routine Provider Information Request (RPIR) – Appraisal tab)

Patient outcomes


Managers monitored the effectiveness of care and treatment and used the findings to

improve them. However, performance in national audits was variable and outcomes for stroke

patients needed improvement.

The medicine division routinely collected information about the outcomes of patients’ care

and treatment. At the last inspection, the medical service did not regularly contribute and review

the effectiveness of care and treatment through national audits. We found this had improved. The

service took part in national and local audits to monitor the quality of care and treatment and

used this information to identify areas of improvement.

Performance in national audits was variable. Performance in the lung cancer audit and was

similar to the national average and the trust was achieving national standards for cardiac

arrhythmia (rhythm management) and coronary angioplasty. Performance in the Sentinel Stroke

National Audit Programme (SSNAP) and the National Falls Audit needed to improve.

The service regularly reviewed the effectiveness of sepsis management through local and

national audit. The trust collected and reported data every month to support the national

commissioning for quality and innovation’ target (CQUIN) for reducing the impact of serious

infections (antimicrobial resistance and sepsis). Data showed an improving trend in the

proportion of patients who received antibiotics within one hour of diagnosis of sepsis. The

quarterly mean compliance for this standard had improved from 76% in April 2018 to 100% in

August 2018.

Relative risk of readmission


From May 2017 to April 2018, patients at the trust had a lower than expected risk of readmission

for elective (planned) admissions and a lower than expected risk of readmission for non-elective

admissions when compared to the England average.

Elective Admissions – Trust Level – medicine division

Non-Elective Admissions – Trust Level - medicine division



From May 2017 to April 2018, patients at Gloucestershire Royal Hospital had a similar too

expected risk of readmission for elective admissions and a lower than expected risk of

readmission for non-elective admissions when compared to the England average.

Elective Admissions - Gloucestershire Royal Hospital

Non-Elective Admissions - Gloucestershire Royal Hospital


From May 2017 to April 2018, patients at Cheltenham General Hospital had a lower than expected

risk of readmission for elective admissions and a lower than expected risk of readmission for non-

elective admissions when compared to the England average.

Elective Admissions - Cheltenham General Hospital

Non-Elective Admissions - Cheltenham General Hospital


Sentinel Stroke National Audit Programme (SSNAP) - Gloucestershire Royal Hospital

Gloucestershire Royal Hospital takes part in the quarterly Sentinel Stroke National Audit

programme. On a scale of A-E, where A is best, the hospital achieved grade D in the latest

audit, August 2017 to November 2017. This is the same overall score as when we inspected the

service in January 2017.

The hospital achieved the lowest scores for speech and language therapy and multi-

disciplinary team working, achieving a grade E in team-centred and patient-centred

performance. The hospital performed well for standards by discharge and discharge processes

achieving either a grade A or grade B in the most recent audit for team centred and patient

centred performance. With regards to team centred performance the hospital has made a big

improvement (grade E to grade C) in its stroke unit when comparing the most recent audit to the

last audit.

Team centred performance

Jan-Mar 16

Apr-Jul 16

Aug-Nov 16

Dec 16 - Mar 17

Apr 17 -Jul 17

Aug 17 - Nov 17

Domain 1: Scanning D C↑ D↓ D D C↑

Domain 2: Stroke unit E↓ D↑ D E↓ E C↑↑

Domain 3: Thrombolysis D D D D C↑ B↑

Domain 4: Specialist assessments E D↑ D D D D

Domain 5: Occupational therapy D D D E↓ C↑↑ C

Domain 6: Physiotherapy E E D↑ D D D

Domain 7: Speech and language

therapyE E E E E E

Domain 8: Multi-disciplinary team working

E E E E E E

Domain 9: Standards by discharge B B A↑ B↓ B A↑

Domain 10: Discharge processes B C↓ C B↑ C↓ B↑

Team-centred total key indicator level

E↓ D↑ D D D D


The SSNAP data above shows intended outcomes for stroke patients were not always

being achieved. We discussed the audit performance with the stroke leads and they told us how

as part of a SSNAP recovery action plan, senior staff and doctors monitored the data every week

to plot the likely trajectory of services against the domains. The most recent data submitted for

team centred performance for April to June 2018 showed:

Domain 1: Scanning C

Domain 2: Admissions to stroke unit C

Domain 3: Thrombolysis B

Domain 4: Specialty assessments B

Domain 5: Occupational therapy D

Domain 6: Physiotherapy E

Domain 7: Speech and Language therapy E

Domain 8: Multidisciplinary team working E

Domain 9: Standards by discharge B

Domain 10: Discharge process B

(Source: SSNAP audit provided by the trust. Please note this data has not been validated.)

Patient centred performance

Jan-

Mar 16

Apr-Jul

16

Aug-Nov

16

Dec 16 -

Mar 17

Apr 17 -

Jul 17

Aug 17 -

Nov 17

Domain 1: Scanning D C↑ D↓ D D C↑

Domain 2: Stroke unit E↓ D↑ D E↓ E D

Domain 3: Thrombolysis D C↑ C D↓ C↑ B↑

Domain 4: Specialist assessments E D↑ D D D C↑

Domain 5: Occupational therapy D D D E↓ C↑↑ C

Domain 6: Physiotherapy E E D↑ D D D

Domain 7: Speech and language

therapyE E E E E E

Domain 8: Multi-disciplinary team

workingE E E E E E

Domain 9: Standards by discharge B B A↑ B↓ B A↑

Domain 10: Discharge processes B C↓ C B↑ C↓ B↑

Patient-centred total key indicator

levelE↓ D↑ D D D D

Overall Scores

Jan-Mar 16

Apr-Jul 16

Aug-Nov 16

Dec 16 - Mar 17

Apr 17 -Jul 17

Aug 17 - Nov 17

SSNAP level E D↑ D E↓ D↑ D

Case ascertainment band A A A A A A

Audit compliance band B B B B A↑ A

Combined total key indicator levelE↓ D↑ D D D D


The stroke service had done a gap analysis and developed an action plan to address the

reasons and barriers preventing the service from achieving the required standards,

especially in the therapy domains. Actions included a discussion about moving stroke

occupational and physiotherapy services to a six-day working model and additional recruitment in

speech and language therapy. At the time of our inspection two additional speech and language

therapists had just been appointed.

From June 2017 onwards, the service had monitored SSNAP performance every week.

Senior staff explained this allowed them to cleanse the data to ensure submissions to the formal

audit were accurate and only data for patients with a confirmed stroke diagnosis was included.

The stroke service at Gloucestershire Royal Hospital took part in relevant quality

improvement initiatives, including an external review conducted by a national stroke care

expert. The review acknowledged significant progress had been made by the team and made

recommendations about how the service could be improved. The recommendations included:

improving access to specialist speech and language assessments and improving consistency of

inbound ambulance calls to the hospital of suspected stroke patients. Additionally, improving the

stroke care skills of nurses and therapists and continuing plans to develop a 14-bed stroke

rehabilitation unit at a local community hospital.

Cardiology audits (Cheltenham General Hospital and Gloucestershire Royal Hospital)

The cardiology service sent a full submission to the following external cardiac audits:

Cardiac Arrhythmia (rhythm management) and Coronary Angioplasty (national audit of

percutaneous coronary intervention (PCI)). In these two audits the trust showed it was

achieving national standards set out in relation to physiological pacing.

The cardiology service sent, but did not meet the required minimum data submission, for

the following external audits: Myocardial Ischaemia National Audit Project (MINAP) and the

Heart Failure Audit. We saw an action plan for the department to increase its data entry but there

were no recorded actions to show how staff would achieve this.

Lung Cancer Audit

The trust performed similar to the national average for most indicators in the lung cancer

audit. The trust took part in the 2017 lung cancer audit and the proportion of patients seen by a

cancer nurse specialist was 60.5%, which did not meet the audit minimum standard of 90%. The

2016 figure was 65.7%.

The proportion of patients with histologically confirmed non-small cell lung cancer

(NSCLC) receiving surgery was 14.6%. This is within the expected range. The 2016 figure was

not significantly different to the national level.

The proportion of fit patients with advanced (NSCLC) receiving systemic anticancer

treatment was 65.4%. This is within the expected range. The 2016 figure was not significantly

different to the national level.

The proportion of patients with small cell lung cancer (SCLC) receiving chemotherapy was

66.7%. This is within the expected range. The 2016 figure was significantly worse than the

national level.

The one-year relative survival rate for the trust in 2017 is 34.7%. This is within the expected

range. The 2016 figure was not significantly different to the national level.

(Source: National Lung Cancer Audit)

National Audit of Inpatient Falls 2017 (Cheltenham General Hospital)

https://www.rcplondon.ac.uk/projects/outputs/nlca-annual-report-2016


The hospital did not meet national aspirational standards in the national audit of inpatient

falls 2017.

The crude proportion of patients who had a vision assessment (if applicable) was 34%.

This did not meet the national aspirational standard of 100%.

The crude proportion of patients who had a lying and standing blood pressure assessment

(if applicable) was 16%. This did not meet the national aspirational standard of 100%.

The crude proportion of patients assessed for the presence or absence of delirium (if

applicable) was 40%. This did not meet the national aspirational standard of 100%.

The crude proportion of patients with a call bell in reach (if applicable) was 71%. This did

not meet the national aspirational standard of 100%.

(Source: Royal College of Physicians)

National Audit of Inpatient Falls 2017 (Gloucestershire Royal Hospital)

The hospital did not meet national aspirational standards in the national audit of inpatient

falls 2017.

The crude proportion of patients who had a vision assessment (if applicable) was 59%.

This did not meet the national aspirational standard of 100%.

The crude proportion of patients who had a lying and standing blood pressure assessment

(if applicable) was 7%. This did not meet the national aspirational standard of 100%.

The crude proportion of patients assessed for the presence or absence of delirium (if

applicable) was 17%. This did not meet the national aspirational standard of 100%.

The crude proportion of patients with a call bell in reach (if applicable) was 71%. This did

not meet the national aspirational standard of 100%.

(Source: Royal College of Physicians)

To address the findings of the national audit of inpatient falls the service had set up a falls

prevention campaign. Senior nurses promoted a campaign called ‘Little things matter’ to remind

staff to complete the falls prevention precautions including: completing falls risk assessments

correctly and leaving call bells in reach of patients. We saw posters with reminders about the

campaign on wards we visited across the trust. The medical division aimed to reduce falls by

10% by March 2019. The service had falls champions on the wards who attended training

sessions and feedback to staff on the wards to improve patient safety.



Staff with different skills and experience worked well together as a team to benefit patients.

All necessary staff, including those in different teams and services, were involved in assessing,

planning and delivering care and treatment. Doctors we spoke with were positive about the

multidisciplinary working on wards. We attended a weekly multidisciplinary team meeting on the

stroke wards at Gloucestershire Royal Hospital and saw the service held extensive, detailed

discussions about each patient. This involved staff from a wide range of teams including therapies,

medical, nursing and psychology. We saw good multidisciplinary working during the board round

on the acute medical unit at Gloucestershire Royal Hospital. Junior doctors were ready with test

results to speed up decision making. We observed positive working relationships between medical

staff with junior doctors being comfortable to ask consultants for advice.


Staff had access to relevant specialist teams and were aware of how to refer to them. For

example, staff on the gastroenterology wards had access to the alcohol liaison team. Staff we

spoke with were positive about the support from the trust’s learning disability and dementia teams.

Allied healthcare professionals, such as physiotherapists, were allocated to wards to

provide consistency of care for patients. On Gallery ward, at Gloucestershire Royal Hospital,

the staff team were led by the clinical specialist physiotherapy lead and the nurse lead. This

ensured integration of the staff teams and ensured a cohesive multi-disciplinary team.

The service had targets for discharging older people by 12 noon with the aim of ensuring

patients were home by lunch time and were not discharged from hospital late at night.

Social workers were based on wards to support complex patient discharges. Nurses we spoke

with were positive about the support from social services and the quick response when patients

were referred.

Discharge summaries with key information about older people with complex needs were

sent to patients’ GPs and community health teams on discharge. This allowed for risk

assessments, including pressure ulcer risk and nutritional risk assessments to be shared.

Seven-day services


Not all services were available seven days a week, although the effect of this on patient outcomes

was being monitored.


The trust aimed to meet NHS Improvement’s four priority standards for seven-day services

by the end of 2018. The trust monitored their performance against the standards. The trust’s

performance against the standards is detailed below:

Standard 2, time to first consultant review, was met in most areas and the trust was

investing in respiratory medicine and cardiology to improve performance against the

standard.

Standard 5, access to diagnostic tests, in cardiology there was a shortfall in access to

diagnostic testing at the weekend across both sites.

Standard 6, access to consultant-directed interventions – cardiology percutaneous

coronary intervention PCI interventions were not available 24 hours, seven days a week.

Patients were transported to other acute hospitals which delivered these treatments.

Standard 8, ongoing review by a consultant twice daily if high dependency.

The trust identified actions for improvement where the standards were not met. For

example, including the seven-day standards in the annual audit programme.

The cardiac catheter laboratory based at Cheltenham General Hospital was not open out of

hours and at weekends, and the emergency department did not admit patients brought in

by ambulance after 8pm. This meant patients were admitted to Gloucestershire Royal Hospital or

to other NHS hospital trusts. This was the level of service provision agreed with the

commissioners. Some discussions had begun about providing a 24-hour service at Cheltenham

General Hospital although the cardiology department was attempting to recruit additional

interventional cardiologists to staff a proposed out of hours rota.

The ambulatory emergency care unit at Cheltenham General Hospital was open from 8am

to 6pm Monday to Friday. At Gloucestershire Royal Hospital, the ambulatory emergency care


unit was open 8am to 6pm, seven days a week. Outside of these hours, patients would attend

their GP or the emergency department for advice on their condition.

The trust had seven-day consultant cover at both sites except for cardiology services. The

trust was in the process of recruiting cardiologists at the time of the inspection. Patients had

access to general X-ray services 24 hours a day, seven days a week. Therapy staff provided care

and treatment Monday to Friday with a reduced service at weekends and out of hours for patients

needing respiratory treatment.

Health promotion


Staff were consistent in their approach to supporting people to live healthier lives. A range of

relevant health promotion leaflets were available on all wards we visited across both sites.

Patients were involved in monitoring their health which included health assessments and

checks. The speech and language therapy department had developed an application to help

patients with aphasia (difficulty forming words). This helped them practice their speech exercises

at home and report on their progress. The app was developed in response to new findings around

aphasia which had shown the recovery periods for some patients were significantly longer than

first thought. Staff told us they actively encouraged patients to use the app as a way of taking

charge of their ongoing recovery.

Some older people’s wards were involved in the End PJ Paralysis scheme to promote

independence. Staff encouraged patients to be up and dressed by midday. It has been shown

that having patients in their day clothes while in hospital reduces falls, improves patient experience

and reduces length of stay. We saw posters asking relatives to bring day clothes in for patients to

promote independence. Staff gave patients attending ambulatory care advice on how to manage

their condition if it worsened and how to seek further help.



Staff understanding of their roles and responsibilities under the Mental Health Act 1983

and the Mental Capacity Action 2005 was at times limited. Most staff we spoke with across

both hospital sites demonstrated a limiting understanding of the Mental Capacity Act in

conversation. Capacity assessments we reviewed were not decision specific and deprivation of

liberty safeguard applications did not adequately describe the proposed restrictions being placed

on the patient.

Staff supported patients in making decisions about their care. For example, at

Gloucestershire Royal Hospital we observed a consultant discussing a patient’s options for

sedation before an endoscopy procedure during a ward round.

Staff asked patients for permission before giving treatment or carrying out examinations.

We saw medical staff asked patients for consent before examining them during ward rounds.

Endoscopy units completed consent audits to comply with accreditation requirements. Staff had

access to an up to date policy on sedation for patients.

The trust provided staff with mandatory training on the Mental Capacity Act and

Deprivation of Liberty Safeguards. This training was provided through an e-learning module.

Additional ward-based training could be provided by the trust safeguarding team on request.

Mental Capacity Act and Deprivation of Liberty training completion


The trust reported as at June 2018 Mental Capacity Act (MCA) training was completed by 92% of

staff in medicine compared to the trust target of 90%.

Name of course Staff trained

Eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)

Mental Capacity Act 792 865 92% 90% Yes

The trust did not provide specific data against deprivation of liberty training.



Compassionate care


Staff cared for patients with compassion. Staff understood and respected the personal, cultural

and social needs of patients and treated them with compassion and kindness. We saw staff

interact with patients and relatives in a positive and respectful manner. They introduced

themselves to the patients in line with the NICE QS15 (Statement 1, Patient experience in adult

NHS services). This standard is about patients knowing the name and role of staff caring for them.

Nurses we spoke with showed a caring, patient-centred attitude. For example, at

Gloucestershire Royal Hospital a nurse on renal ward (4B) explained how they enjoyed getting to

know patients as they often returned to the ward throughout their treatment. All staff spoke in a

non-judgemental way towards patients with mental health needs and learning disabilities.

Staff told us they would raise concerns about disrespectful or abusive behaviour or

attitudes displayed by other staff and explained this would not be in line with the trust’s

core values. Staff showed sensitive and supportive attitudes towards patients. At Cheltenham

General Hospital, we saw nurses on the coronary care ward take their time when delivering

personal care to patients, allowing them as much time as they needed to complete basic hygiene

tasks.

Staff on the stroke ward at Gloucestershire Royal Hospital took considerable time to assist

a recovering patient eat their breakfast. The nurse was patient, kind and encouraging while

maintaining the patient’s dignity where possible. At Cheltenham General Hospital, the sister on

Snowshill ward was friendly, approachable and had in depth knowledge of all patients. We saw

them trying to find an ice lolly for a patient who was struggling to eat.

Friends and family test performance

Friends and family test results were good. The average annual performance being above 80%

for all wards at Cheltenham General Hospital and above 70% for all wards at Gloucestershire

Royal Hospital.

The response rate for medicine from July 2017 to June 2018 was 27% which was better

than the England average of 25%. A breakdown by site and ward can be found below.



Ward name

Total

Res

p

Resp

.

Rate

Percentage recommended

Jul-

17

Aug-

17

Sep-

17

Oct-

17

Nov-

17

Dec-

17

Jan-

18

Feb-

18

Mar-

18

Apr-

18

May-

18

Jun-

18

Ann.

Perf

.

ACUC 561 28% 89% 84% 93% 87% 89% 90% 95% 84% 91% 84% 94% 87% 89%

Avening Ward 212 23% 94% 100% 85% 83% 88% 82% 86% 88% 84% 100% 91% 88% 89%

Cardiac Ward 388 36% 96% 90% 93% 100% 94% 95% 94% 87% 97% 94% 89% 94% 94%

Hazelton

Ward 193 26% 76% 79% 91% 100% 90% 80% 80% 100% 73% 100% 93% 90% 88%

Lilleybrook

Ward 168 18% 92% 92% 90% 100% 100% 71% 94% 100% 100% 100% 85% 100% 93%

Rendcomb

Ward 152 20% 100% 100% 100% 75% 100% 89% 100% 100% 100% 95% 100% 100% 97%

Ryeworth

Ward 132 19% 90% 75% 75% 69% 100% 71% 100% 90% 70% 84% 100% 82%

Woodmancot

e Ward 165 19% 88% 81% 88% 89% 73% 88% 89% 76% 74% 78% 79% 81%


Emotional support


Staff provided emotional support to patients and families. Staff supported patients who

became distressed in an open environment and assisted them to maintain their privacy and

dignity. Ward staff used day rooms to allow patients to have a private space. On acute medical

Ward name Total

Resp

Resp

.

Rate

Percentage recommended

Jul-

17

Aug-

17

Sep-

17

Oct-

17

Nov-

17

Dec-

17

Jan-

18

Feb-

18

Mar-

18

Apr-

18

May-

18

Jun-

18

Ann.

Perf.

AMU 633 24% 89% 83% 77% 85% 89% 80% 90% 74% 82% 84% 83% 83%

Cardiology 314 31% 90% 93% 88% 85% 96% 91% 89% 97% 95% 84% 96% 91%

Gallery Wing

Ward 1 121 18% 63% 57% 80% 92% 50% 86% 90% 54% 90% 71%

Ward 4b 145 21% 73% 67% 83% 57% 55% 84% 92% 83% 81% 70% 87% 77%

Ward 6b 248 27% 92% 100% 85% 82% 85% 79% 78% 84% 90% 83% 91% 96% 88%

Ward 7a 201 19% 82% 93% 79% 76% 92% 93% 81% 78% 56% 68% 77% 84% 81%

Ward 7b 152 19% 56% 78% 80% 67% 100% 78% 83% 94% 78% 92% 88% 63% 82%

Ward 8a 201 23% 80% 71% 75% 76% 100% 80% 80% 92% 89%

100

% 86% 79% 84%

Ward 8b 274 24% 100% 85% 93% 93% 74% 82% 96% 83% 77% 83% 78% 80% 85%

Ward 9b 114 20% 86% 85% 67% 69% 75% 83% 78% 80% 73% 78% 70% 76%


units, interview rooms were available, although they were small, and not always the best

environment.

Patients, and their families, who received life-changing diagnoses were given appropriate

emotional support and had access to further support services. For example, on the oncology

ward at Cheltenham General Hospital, patients could access a dedicated day centre which

provided practical support to help patients cope with the financial impact their diagnosis might

have on their life. In addition, the centre provided a range of complimentary activities and classes,

which were open to staff as well. At Gloucestershire Royal Hospital, when staff needed to inform

patients of a life-changing diagnosis this staff told us this would always be done in a private room

with a doctor and a cancer specialist nurse, so any questions could be answered, and the patient

supported appropriately.

Emotional and spiritual support and information was available for patients and their

families and carers. The trust had a department for spiritual care which supported patients and

their relatives and carers. The service offered bedside ministry for patients who could not attend

the chapel or prayer room. At Cheltenham General Hospital there was a chapel and a prayer

room, which were open 24 hours a day.

Staff could access specialist staff to provide emotional support to patients. For example,

staff on the neurology wards at Gloucestershire Royal Hospital told us they received a good

service from the health psychology service.



Staff involved patients and those close to them in decisions about their care and

treatment. Staff made sure people who used services and those close to them could find further

information, including community and advocacy services, or ask questions about their care and

treatment. Ward rounds we saw were unhurried and allowed patients enough time to discuss

their care and treatment.

Staff told us they understood the impact some illnesses and conditions had on the whole

family, not just patients, and always involved relatives and carers in as many aspects of

care as they could. Staff identified the people important to patients and treated them as important

partners in the delivery of their care. We saw staff greeting families as they arrived to visit

relatives, and we saw relatives approach staff to request to speak with senior or medical staff. In

all cases, nurses arranged for families and carers to have conversations with medical staff.

Staff empowered and supported patients where necessary and signposted them to support

networks to improve their health and wellbeing. For example, at Cheltenham General Hospital

we saw information displayed on the oncology ward for specific support groups available through

the onsite support centre. On the stroke wards at Gloucestershire Royal Hospital, staff could refer

patients to clinical psychologists for extra support with their ongoing recovery and treatment.

Staff on both sites routinely involved people who used services and those close to them in

planning and making shared decisions about their care and treatment. Patients and relatives

told us they felt listened to and respected as staff considered their views. On the stroke wards at

Gloucestershire Royal Hospital, speech and language therapy staff told us of specialist

communication books they used to help recovering patients communicate their needs with staff

and their family. All wards had open visiting times, between 9am and 9pm. Staff encouraged

people close to patients to visit and be involved in patient care, for example by helping at

mealtimes. Senior nurses told us open visiting times supported patient safety and wellbeing.


When older people with complex needs were being discharged, staff involved those close

to the person so appropriate clothing could be brought to hospital. At Cheltenham General

Hospital, staff on the oncology ward explained they had sealed disposable bags for patients to

take soiled items home with them. Staff told us of an occasion where a patient had no clean

clothes to go home in, so they could access a small emergency budget through social services to

purchase some clothing for the patient to be discharged in. On the stroke wards at Gloucestershire

Royal Hospital, we saw medical staff discussing home life and mobility with patients. Staff

discussed support agencies and charities which may help provide ongoing information for patients

about specific aspects of their recovery, such as mobility and driving.

Consultants explained patients’ diagnosis and treatment plans during ward rounds and

gave patients the opportunity to ask questions about their care. For example, on ward 7A at

Gloucestershire Royal Hospital, we observed a consultant explain a patient needed an

endoscopy and fasting times were explained to the patient.

Staff introduced themselves to patients by name and explained their role. On ward 7A we

saw posters on the wall encouraging patients to ask doctors questions - ‘Your doctor will have the

answers, please just ask’.

Is the service responsive?

Service delivery to meet the needs of local people


The trust did not always plan and provide services in a way that met the needs of local people.

Services did not always reflect the needs of the population served and did not always ensure

flexibility, choice and continuity of care.

Progress with plans to improve the quality and safety of cardiac services had not

sufficiently progressed since our last inspection. The cardiac services were provided in the

same was as at our last inspection and this level of service provision was agreed with

commissioners. The cardiac catheter laboratory at Cheltenham General Hospital was not open out

of hours and at weekends, and the emergency department at Cheltenham did not admit patients

brought in by ambulance after 8pm. This level of service provision was agreed with the

commissioners. Patients were admitted to Gloucestershire Royal Hospital or to other NHS hospital

trusts for treatment. Some discussions had begun about providing a 24-hour catheterisation

laboratory service at Cheltenham General Hospital. The cardiology department was looking to

recruit extra interventional cardiologists to staff the out of hours rota. The department had four

consultant cardiologists but required six to make the rota sustainable.

Senior Cardiologists had recently presented their findings on the effect the location of

services was having on patient outcomes for those patients firstly admitted to

Gloucestershire Royal Hospital. Data collected over a six-year period between January 2012

and September 2018 showed patients needing primary percutaneous coronary intervention (PCI)

transferred from Gloucestershire Royal hospital to Cheltenham General hospital had a 10% 30-

day mortality rate compared to a 5% 30-day mortality rate. Patients transferred from

Gloucestershire Royal hospital had a 5% higher mortality risk that those directly admitted to


Although it had not yet been put into action, the cardiology team had undertaken work with

the local NHS ambulance trust to allow the on-call cardiologists to remotely review patients


in their homes when paramedic crews arrived, using the same software used by the

paramedics. The department had bought two laptops which could be taken home by the on-call

cardiologist to help them determine more accurately where the ambulance crew should take the

patient. The objective was to review patients’ echo cardiograms (ECGs) remotely, the trust aimed

to reduce the need for cross-site transfers after patients had initially been admitted at

Gloucestershire Royal Hospital. However, at the time of inspection this new process had not

commenced but formed part of the 24-hour interventional cardiologist and catheterisation

laboratory rota plans.

There were innovative services to meet the needs of the population. For example, at

Gloucestershire Royal Hospital, the brain injury team had established an integrated care model

which allowed therapists to continue treating patients after discharge. Patients could access the

service through outpatient appointments to support their rehabilitation. The early discharge team

visited patients at home to deliver specialist therapy. The model of care was an example of best

practice and had been established for over ten years with support from NHS specialist

commissioners.

There were improvements underway for stroke patients, including more input from

therapists. The stroke care service based at Gloucestershire Royal Hospital, had been re-

configured to reduce the number of stroke beds by 14, from 61 to 47. The 14 beds were being

moved to a nearby community hospital for stroke rehabilitation. At the time of inspection, the plans

had gone through public consultation and the last members of additional therapy staff were being

recruited. Senior managers planned for the service would be up and running before the end of

December 2018. Because of the reconfiguration, the trust aimed for existing therapy staff at

Gloucestershire Royal Hospital to have more time to spend with patients, as there was to be no

reduction in therapy staffing numbers after the re-location of stroke beds. The stroke service had

analysed face-to-face time given to patients based on current staffing numbers with both the

current and revised numbers of beds. This data showed, at the time of inspection, physiotherapists

were 2.52 hours a week short of the Sentinel Stroke National Audit Programme (SSNAP) target to

provide five 45-minute sessions on five out of seven days for 50% of patients. Under the new

service configuration this shortfall was reduced to 0.68 hrs. For occupational therapy, the shortfall

was 0.65 hours rising to a surplus of 0.84 hours after reconfiguration. For speech and language

therapy, the shortfall was 2.19 hours falling to 1.45 hours after reconfiguration.

Stroke patients had limited access to video fluoroscopy tests for patients who had

difficulty swallowing (this is a test involving x-ray screening of a patient’s throat as it

swallows barium coated foods or thickened liquids to see if anything leaks into the

patient’s trachea). An external review found there was no inpatient video fluoroscopy service for

patients on the stroke wards. As an alternative, fibreoptic endoscopic evaluation of swallowing

(FEES) could be performed, using special cameras to look at a patient’s throat. The review noted

there were no trained specialists to use the equipment. At the time of inspection, two speech and

language therapists had been trained to perform FEES assessments but access to video

fluoroscopy remained limited to one session a fortnight. There was a four-month waiting list for the

video fluoroscopy clinic at the time of inspection. The impact on patients was that they would have

enteral (tube) feeding for longer than is necessary and there was a risk that some patients may be

fed normally despite a risk of silent aspiration (food going down the wrong way when the patient

had no or a limited cough response).

Gloucestershire Royal Hospital had arrangements for ambulatory care including an

ambulatory emergency care unit, an acute medicine initial assessment area and a medical

day unit. Patients who were judged well enough to sit in the waiting area and have tests done and


treatment before being discharged the same day were treated in ambulatory emergency care. The

ambulatory emergency care unit was open between 9am and 9pm. The unit was located with the

acute medicine initial assessment area (AMIA). In the AMIA, patients were admitted for a short

stay for treatment and not overnight. The AMIA unit closed at 10pm. At Cheltenham General

Hospital, the ambulatory emergency care unit was open Monday to Friday 8am to 6pm, the last

patient was accepted at 4pm to allow time for tests and discharge.

The medical day unit provided care and treatment from Monday to Saturday. The admission

criteria stated patients needed to be able to sit in a chair for their treatment. There was one trolley

space which was used for patients to recover following a liver biopsy. The medical day unit

provided treatment such as blood or iron transfusions and helped prevent overnight hospital

admission beds.

At the time of inspection, the winter management plan for the medicine division was not yet

finalised. This was late in the year for the plan not to be available to staff. The plan was due to be

presented to the executive board shortly after our inspection. The winter management plan

provided guidance for staff on managing patient flow safely during times of increased medical

admissions. The trust submitted a 2018/19 winter planning briefing statement as part of the

inspection process which outlined actions to manage increased demand over winter. For example,

the briefing included increased use of the acute medical initial assessment area (AMIA) to prevent

hospital admissions and having a respiratory consultant based in the AMIA to provide specialist

review of patients.

Most facilities and premises were appropriate for the services delivered. Most wards had day

rooms for patients and families to use. Wards across both sites had been adapted to be dementia-

friendly environments with clear signage.

The service was making plans to manage the 8% increase in demand for medical services.

This increase in demand was reported by the trust and was due to an increase in patients needing

admission to a medical bed from the emergency department. For example, the trust planned to

open a frailty assessment service in December 2018. The aim of the frailty service was to reduce

hospital admissions for older people. Other service developments included a consultant from a

local acute hospital running an outpatient clinic once a week for renal transplant patients on the

renal ward (4B) at Gloucestershire Royal Hospital. Staff told us they had got positive patient

feedback about this service.

Average length of stay - Trust Level

The length of stay for patients was mostly below (better than) the England average. Most

patients were therefore able to be discharged quicker than on average. From June 2017 to

May 2018, the average length of stay for medical elective patients at the trust was 5.5 days,

which is lower (better) than the England average of 6 days. For medical non-elective patients, the

average length of stay was 5.8 days, which was lower (better) than the England average of 6.4

days.

Elective Average Length of Stay – Trust Level


Note: Top three specialties for specific trust based on count of activity.

Non-Elective Average Length of Stay – Trust Level



From June 2017 to May 2018, the average length of stay for medical elective patients at

Cheltenham General Hospital was 4.9 days, which was lower (better) than England

average of 6.0 days. For medical non-elective patients, the average length of stay was 5.7 days,

which was lower (better) than England average of 6.4 days.

Elective Average Length of Stay - Cheltenham General Hospital

Note: Top three specialties for specific site based on count of activity.

Non-Elective Average Length of Stay - Cheltenham General Hospital





From June 2017 to May 2018, the average length of stay for medical elective patients at

Gloucestershire Royal Hospital was 7.3 days, which is higher (worse) than England

average of 6 days. For medical non-elective patients, the average length of stay was 5.8 days,

which is lower (better) than England average of 6.4 days.

Elective Average Length of Stay - Gloucestershire Royal Hospital


Non-Elective Average Length of Stay - Gloucestershire Royal Hospital





The service took account of patients’ individual needs, including those in vulnerable

circumstances. Services were delivered and coordinated to be accessible and responsive to

people with complex needs. The service identified patients with a disability or sensory loss through

the admission process. Staff used a butterfly symbol to raise awareness of any patient with a

cognitive impairment. However, we saw the use of these symbols varied in consistency from ward

to ward.

Staff supported patients living with dementia well. For example, on the cardiac wards at

Cheltenham General Hospital, the dementia lead nurse spoke of plans to establish a dementia

information board for staff, patients and relatives. They explained they had good access to training

if needed. Clinical guidelines produced by the National Institute for Health and Care Excellence

(NICE, NG97 June 2018) recommended all staff have access to dementia training. Data showed

82% of registered and non-registered nursing staff and doctors (excluding locums) had completed

dementia care training as of 30 September 2018.

Staff encouraged patients living with dementia to be involved in social activities. For

example, at Gloucestershire Royal Hospital, a volunteer worked on Gallery ward and focused on

providing activities such as bingo, a harvest festival, concerts and singing. Events were celebrated

such as the royal wedding, Easter, Halloween and staff and patients had shared afternoon tea in

the day room to celebrate. On ward 9B, a healthcare assistant ran a dementia group where

patients could have lunch together in the day room followed by activities such as bingo or potting

plants. Staff had access to a portable electronic device staff could use to support reminiscence

activities for patients living with dementia. Positive feedback from patients about the ‘cognitive

stimulation group’ was displayed on the ward. For example, one comment from a patient read

‘staff made everyone felt equally important.’

We reported at the last inspection, the trust was introducing ‘This is Me’ booklets for

patients living with dementia. In these documents, relatives could add information about the

patient to help inform nurses and other healthcare professionals of specific likes and dislikes to

improve understanding and communication with the patient. Most wards we visited on both sites

used the document. Staff involved patient’s carers to find out about their individual preferences to

enable more person-centred care. Staff used the ‘This Is Me’ booklet across all wards for people

living with dementia

The service had implemented some improvements for people living with dementia on the

wards, including the use of ‘twiddle muffs’. These helped to stop patients with dementia pull at

infusion lines or catheters which could cause harm. The ‘twiddle muffs’ were given to patients for

their stay in hospital and were only used by one person to prevent the spread of infection. Staff we

spoke with generally showed a good awareness of the needs of people living with dementia.

The service had a dementia liaison and a learning disability team to support staff caring for

patients with their individual needs. All staff we spoke with described good support from

dementia and learning disability liaison nurses. The dementia and learning disability liaison nurses

worked Monday to Friday 9am to 5pm. Staff were very positive about the involvement of the

learning disability team from the point of admission onwards.

The hospital trust needed to improve upon the assessment of its environment for people

living with dementia as given by patients. The 2018 patient led assessment of the care

environment (PLACE) score showed Cheltenham General Hospital and Gloucestershire Royal

Hospital both achieved 69% for dementia awareness; lower than the national average score 79%.

This score is for the whole hospital site not just the medicine division.


There were suitable arrangements to support staff caring for and to support people with a

learning disability. Staff could identify aids such as picture boards to help with communication.

Staff knew how to access the learning disability liaison nurse who was involved in discharge

planning for patients with learning disability. We listened as staff discussed the care needs of a

patient with a learning disability at length during a medical handover. This ensured the patient’s

involvement in decision-making and care and treatment was appropriate. The trust employed two

learning disability nurses and had access to the mental health crisis team. Mental health liaison

was available at all times.

Staff made appropriate discharge arrangements for people with complex health and social

care needs. Social workers, occupational therapists and the integrated discharge team worked to

support patients to be discharged as quickly as possible with the right support. Staff we spoke with

told us discharges were often delayed due to difficulties finding placements for people with mental

health needs and learning disabilities. At Gloucestershire Royal Hospital, staff from Gallery ward

worked closely with the discharge team to identify suitable patients for admission to this ward,

which cared for patients who were medically fit for discharge. Staff attended a daily meeting with

the onward care team, adult social care representative and a care navigator to identify suitable

patients and expedite patient discharges. A daily board meeting took place on the ward which

focused on discharge planning and arranging extra support for patients.

During the inspection, we saw discharge waiting areas were used appropriately. There were

reading materials and a television for patients and those waiting with them.

Staff knew how to access interpreting services for patients whose first language was not

English. Interpreting services were available by phone, or face-to-face interpreters and could be

booked in advance. We were told the trust priority was not to use staff members or family as

interpreters. We saw one example where a doctor at Cheltenham General hospital reminded other

staff using family members was not in line with best practice and booked an interpreter for the

patient.

However, during our inspection staff were caring for a patient whose first language was not

English in the discharge waiting area at Gloucestershire Royal Hospital and staff did not

contact interpretation services to help communicate with the patient. Ward staff had

informed the patient their discharge arrangements as they had spoken with a relative on the phone

who had translated and informed the patient. The staff said they would use sign language to

communicate about food and drink but the arrangements for discharge and medicines had been

discussed on the ward.

Staff reported the interpreting service was not always reliable. For example, on the stroke

and neurology wards, some staff reported there had been several occasions where interpreters

had not arrived as planned when they were booked. These incidents had been reported through

the trust’s electronic incident reporting system, but staff were unaware of any actions which had

been taken as a result.

Access and flow


Patients did not always have access to care and treatment in a timely way. Most medical

specialities did not meet national targets for referral to treatment times. At the time of the

inspection, the trust had calculated for treatment times, it was not meeting NHS England targets

for 90% of admitted patients and 95% of non-admitted patients to start treatment within 18 weeks

of referral.


The trust had not taken sufficient action to monitor those patients waiting for a year or

more. To manage the risk of patient harm, the trust was monitoring patients waiting more than 52-

weeks in advance at the 45-week stage. General managers were picking a random sample of 20

patients to carry out ‘harm reviews’ and had begun this work shortly before our inspection in

October 2018. However, we were not assured the trust sufficient action to ensure patients did not

come to harm while waiting for treatment.

Referral to treatment (percentage within 18 weeks) - admitted performance

The trust has been unable to report referral to treatment data to NHS England since

November 2016. This was due to problems with data quality following the introduction of a new

electronic patient record system in December 2016.

(Source: NHS England)

The following data was reported by the trust in their referral to treatment action plan. This data

has not been externally validated.

Performance against 18-

week target

April 2018 May 2018

General medicine 57.2% 72.7%

Neurology 61.0% 68.9%

Diabetes and endocrinology 66.8% 74.4%

Cardiology 53.1% 74.7%

Respiratory 63.8% 74.5%

Dermatology 67.3% 75.7%

Renal 84.3% 91.2%

Gastro & Endoscopy 76.2% 79.5%

Rheumatology 56.2% 59.0%

(Source: P87.1 – item 10.2 –action plan – trajectory)

The medical division had a referral to treatment action plan to minimise the length of time

people had to wait for care and treatment. The action plan included a trajectory for achieving

referral to treatment targets. Actions included training clinicians around the use of patient record

system to improve data, prioritising patients, and validating data. The trust monitored referral to

treatment performance on the medicine performance dashboard.

There was a risk that patients did not always have timely access to some diagnostic tests

in the cardiac catheterisation laboratory at Cheltenham General hospital. Staff told us, and

showed us, the extra standalone electronic referral system used by junior doctors and consultants

to refer patients for interventional cardiac tests. Staff explained there was sometimes confusion

when junior doctors were new to the department as most assumed referrals for diagnostic imaging

procedures could be made on the generic electronic referral system. To address this, the service

had developed a standard operating procedure to give new doctors and remind established ones

of the unique referral pathway and avoid referrals sitting on the system un-processed. The service


monitored all referral dates against admission dates to make sure patients were prioritised in order

of urgency, and to check for missed referrals.

The service managed patients admitted to non-medical wards well. Medical outliers are

patients admitted to wards which do not usually provide care and treatment for their medical

condition. When medical wards were full, medical patients were usually placed on surgical wards.

The medical care and treatment of outlier patients was the responsibility of a nominated doctor.

The trust electronic patient information system identified whether the patient was admitted for

medical or surgical care and the name of the responsible doctor. The site management meeting

produced a list of patients on other wards each morning at 8am. Staff on surgical wards caring for

medical patients knew how to contact appropriate medical staff when needed. Nurses told us

medical teams visited outliers daily and responded promptly if the patient needed a medical

review. However, they had experienced delays when the medical support was not an emergency.

For example, re-writing a prescription or prescribing medicine to take home. This had at times

delayed the patient’s discharge. Where possible the nursing staff planned for discharge at least

two days in advance to help prevent delays.

The trust managed demand for medical beds and capacity well. Bed capacity review meetings

happened throughout each day which identified any issues with flow, admissions, discharge

planning and the need for escalation. There were four planned joint meetings between the two

hospitals which were led by senior staff. We attended three at Gloucestershire Royal hospital and

two at Cheltenham General hospital. The meetings were attended by senior representatives,

including matrons from medicine, and the other clinical divisions. We saw staff at the meetings

were focused on managing flow through the hospital safely. From 5pm each day, the on-call

director attended by telephone. Staff reported on the number of available medical beds and

potential discharges. Medical patients on non-medical wards were discussed and assurances

obtained that medical staff were aware and would carry out a review. The site management team

tried to repatriate the medical patients to their specialist ward when beds became available.

At the time of the inspection, there were no escalation wards open at either hospital site.

Escalation wards were for extra inpatient beds opened in times of increased demand. However,

wards could be opened at short notice when demand was high. At Cheltenham General hospital

we observed the site management team arranging to open escalation beds on Kemerton ward, a

day surgery unit. Extra staffing was resourced throughout the day, so the unit could stay open and

admit medical patients. However, it transpired later in the day that the ward was not required as

the patients were all admitted into established beds within the trust. The bank and agency staff

who had been booked were re-deployed into other areas which had been identified as needing

extra resources.

Patient flow through the hospital was managed well. A trust-wide site management team

coordinated patient flow through both hospitals. The team visited all wards every morning to

gather information about the capacity of the wards. The site team was developing link roles to

ensure they had the knowledge and skills to plan transferring patients with complex needs to

different wards and departments. The onward care team provided information at each site meeting

for the patients who were potentially being discharged that day and for the next day. This enabled

forward planning to take place for patients who required admission to the hospital or medical

patients on non-medical wards who required transfer to a specialist ward.

Staff reviewed patients estimated discharge dates regularly. For example, on stroke wards at

Gloucestershire Royal Hospital, board rounds involved medical, nursing and therapies staff. They

included a detailed discussion of the plan for each patient’s care and estimated discharge date,

including an update of the patient’s condition overnight. Staff used ‘Red2Green’ approach used


during board rounds in the morning and afternoon. The ‘Red2Green approach is a way of

improving the patient discharge process by focusing on how a patient’s time is spent in hospital.

‘Red days’ are days where there is no activity that supports a patient getting better and be

discharged. ‘Green days’ are days when patients receive interventions that support their care and

treatment and safe discharge. In board rounds we observed, staff identified actions to progress

patients towards discharge and these were followed up at the afternoon board meeting.

Trust escalation processes worked well. The trust used the nationally recognised Operational

Pressures Escalation Framework (OPEL) which indicated the pressures and capacity of the

system. The framework identified four levels of operational pressure which were colour-coded:

green (level one), amber (level two), red (level three) and black (level four). Level four was the

highest level of operational pressure and was known as OPEL four or black escalation.

Escalation could change quickly and required a quick response. During our inspection, for

example, the OPEL status of the trust increased from amber (level two), to red (level three) and

into black (level four) before returning to amber (level two). The OPEL rating was calculated by

reviewing the bed deficit (predicted admission, actual admissions and actual and potential

availability of beds), the total number of admissions to the emergency department and the number

of discharges. At times of escalation, the site management team sent emails to heads of divisions,

senior managers and the directors to alert them of the potential impact on the flow of the hospital.

When the OPEL status was escalating, extra meetings were called. We saw on day two of our

inspection an additional meeting was held to review the actual and potential availability of beds to

help reduce the pressures on the emergency department.

The service had a ward (Gallery ward) for medically stable patients who were unable to

return home due to complex discharge arrangements. On Gallery ward, the responsibility for

patient care was shared between therapy and nursing staff with a focus on independence and

rehabilitation. On this ward average length of stay was five days. The length of stay on this ward

was longer than other wards as this ward was used for medically fit patients who were waiting for

community placements and packages of care.

Staff used discharge waiting areas and day rooms effectively. There was a discharge waiting

area (DWA) at Gloucestershire Royal Hospital which opened from 8am to 8pm seven days a

week. Staff used the DWA to care for medically fit patients who were waiting for transport to take

them home. This meant patients could leave the ward earlier. Cheltenham General Hospital did

not have a discharge waiting area but used day room facilities on wards where patients could wait

for medicines and transport home. This meant the beds could be released for other patients.

The back doors of the DWA were used by staff and visitors to other areas of the hospital as

an access route. The doors were often left open which provided additional pressures to the

department in monitoring patients living with dementia who were in the unit as they potentially

could leave the building unaccompanied. Staff said this had been reported but no action taken.

Patient moving wards at night

The site management team worked to avoid discharging patients out of hours and reviewed

the number of bed moves at night. The trust recognised this was unavoidable at times but

wanted to reduce the impact upon patients.

From July 2017 to June 2018, there were 8,790 patient moving wards at night within medicine. A

breakdown of ward moves at night by site can be found below:

Cheltenham General Hospital: 2,305 ward moves at night (1,322 moves at night were

assigned to the acute care unit).


Gloucestershire Royal Hospital: 6,485 ward moves at night (4,549 moves at night were

assigned to the acute care unit).

(Source: Routine Provider Information Request (RPIR) – Moves at night tab)



The service treated concerns and complaints seriously, investigated them and learned

lessons from the results, and shared these with staff. Patients we spoke with were aware of

how to make a complaint or raise a concern about the service, if necessary. Information leaflets on

how to make a complaint were available in all the areas we visited.

We reviewed the trust’s responses to the last three complaints to the medicine clinical

division. We saw the trust responded to complaints an open and honest way and kept people

informed of the progress of their complaint. People were told how to take their complaint further,

where appropriate, for example by contacting the clinical commissioning group or the

Parliamentary and Health Service Ombudsman. The trust responded to all three complaints in 35

working days.

The trust monitored timeliness of response to complaints at the monthly quality board

meeting. Complaints were reviewed and responded to by the relevant medical consultant, matron

or senior nurse so a response could be drafted.

The trust used concerns and complaints as an opportunity to learn and drive improvement.

Senior nurses discussed learning from complaints and shared compliments at ward team

meetings. For example, minutes from the August 2018 ward meeting on 9B showed one complaint

was received in July that related to medical rather than nursing issues and a compliment was

received from relatives of a patient who had died on the ward.

Summary of complaints

From April 2017 to March 2018, there were 206 complaints about medical care at the trust.

The trust took an average of 37.4 days to investigate and close complaints. This was just above

the deadline with the complaints policy, which stated complaints should be completed within 35

days.

The six most common subjects of complaint in the trust were:

Complaint Detail Complaints


Communications 34

Appointments 26




The breakdown by site is shown in the table below.



From April 2017 to March 2018, there were 55 complaints about medical care at

Cheltenham General Hospital. The trust took an average of 39.2 days to investigate and close

complaints, this is not in line with their complaints policy, which states complaints should be

completed within 35 days.



Communications 9

Appointments 7



Prescribing 2

Waiting Times 2


End of life care 1

Facilities 1


Trust admin/policies/ procedures including patient record

management

1


From April 2017 to March 2018, there were 151 complaints about medical care at

Gloucestershire Royal hospital. The trust took an average of 36.7 days to investigate and

close complaints which was just above its complaints policy deadline, which stated complaints

should be completed within 35 days.



Communications 25

Appointments 19






Other 4

End of life care 3

Prescribing 3


management 3


Waiting Times 2


Number of compliments made to the trust

From April 2017 to March 2018 there were 2,963 compliments within medicine at the trust.

The breakdown by site is shown in the table below:

Location Compliments

Cheltenham General Hospital 625

Gloucestershire Royal Hospital 2,334

(Source: Routine Provider Information Request (RPIR) – Compliments tab)


The same trust wide leadership team managed Cheltenham General Hospital and Gloucestershire

Royal Hospital. We have reported about the leadership of the two hospital sites together and

made the same judgements across both sites.

Leadership

Managers at all levels in the trust had the right skills and abilities to run a service providing

high-quality sustainable care. Leaders had the skills, knowledge and experience needed to lead

the medicine clinical division effectively. A chief of service, a divisional chief nurse and a divisional

operations director led the division. Senior leaders told us they had worked on improving the

leadership structure of the medicine division since the last inspection. At the time of inspection, six

matrons worked across the two hospital sites.

Leaders understood the challenges to quality and sustainability and identified actions to

address them. Since the last inspection, the medical leadership team had focused on improving

the flow of patients through the hospital. The biggest challenges to the service was an 8%

increase in activity across both sites and managing nursing and medical staff vacancies. To

address the challenge of high levels of vacancies for nurses and junior doctors, the service was

introducing advanced clinical practitioner (ACP) nursing posts to complement and undertake some

of the roles of medical staff. The trust had an international recruitment programme to recruit

doctors from overseas.


Staff we spoke with described all levels of leadership as visible and approachable. Nursing

staff said matrons visited wards every day. Staff said their managers were supportive and they felt

listened to if they raised a concern. Freedom to Speak Up Guardians were available to staff if they

wanted to raise an issue.

Staff were positive about senior leadership. For example, we were told the deputy chief of

service was very visible and practical on the acute medical ward at Gloucestershire Royal

Hospital. The site management team were positive about the executive team and felt the director

of nursing was visible and supportive.

Senior leaders described how the chief operating officer had empowered clinical teams and

created a good culture of support and constructive challenge. The service had clear priorities

for ensuring sustainable and effective leadership. Band six nurses across both sites had access to

leadership training courses. The director of nursing was the board lead for mental health. Trust

governors were involved in the mental health strategy, and there was a governor lead for mental

health.

Vision and strategy

The medical division was in the process of developing a formal divisional strategy at the

time of the inspection. The medicine division was developing strategies at speciality level

through engagement with staff. The division engaged with staff in May 2018 in a series of

speciality specific ‘big discussion’ groups to discuss service developments. We reviewed example

presentations for diabetes & endocrinology, cardiology and care of the elderly, and saw meetings

covered areas of progress, challenges and plans. The big discussion meetings provided

information to the ‘centres of excellence board’, the service development group and sustainability

and transformation partnerships (STPs). These discussions were part of developing submissions

to the trust’s ‘journey to outstanding’ improvement strategy. The ‘journey to outstanding’ was the

trust strategy to improve services and achieve an outstanding CQC rating. We saw information

about the ‘journey to outstanding’ displayed on wards we visited. Following the ‘big discussion’

meetings, service leads planned to develop an overarching medical division strategy that would

align with the trust priorities for delivery of care over the next three to five years. The trust aimed to

reconfigure services across both sites by 2021 to reduce inefficiencies and improve the safety and

quality of care.

The speciality level strategies aligned to local plans in the wider health and social care

economy. For example, plans for a frailty assessment service aimed to reduce the number of

unnecessary admissions to medical wards and care for people in their home environment

wherever possible. As we reported above, stroke services were being reconfigured to provide

more community-based rehabilitation.

At Gloucestershire Royal hospital, the trust had re-configured stroke services to reduce the

number of stroke beds by 14 and move those beds to a nearby community hospital for

stroke rehabilitation leaving 47 beds at the acute site. At the time of inspection, the plans had

gone through public consultation and senior managers aimed for the service to be running by the

end of December 2018.

Culture

Managers across the trust promoted a positive culture that supported and valued staff,

creating a common purpose based on shared values. Most staff we spoke with felt supported,

respected and valued. Ward managers and sisters told us how proud they were of the strong team

working and commitment of staff to patient-centred care. Staff we spoke with were proud to work


at the trust. On the oncology wards at Cheltenham General Hospital, staff told us of several

initiatives around staff health and mental wellbeing. Schwarz rounds were used to allow staff to

meet and discuss experiences around a set theme in a safe and supportive environment. Schwarz

rounds are a group reflective practice forum which provides an opportunity for staff from all

disciplines to reflect on the emotional aspects of their work.

Senior nurses we spoke with showed a strong focus on patient safety. Senior nurses were

well-engaged with NHS patient safety collaboratives to reduce patient falls, pressure ulcers and

hospital-acquired infections.

Staff described an open culture and were confident to raise any concerns with their

manager or somebody more senior. Staff had yearly appraisals carried out by line managers to

identify opportunities for development. Nursing staff we spoke with were positive about training

and development opportunities.

Governance

The trust used a systematic approach to continually improve the quality of its services and

safeguarding high standards of care. There were effective structures, processes and systems

of accountability to support the delivery of the strategy and good quality, sustainable services. The

medicine division had formal governance structures which fed up through the management teams

up to a monthly medical divisional board meeting.

Medical specialities had their own governance meetings and these fed into monthly

executive reviews. Matrons represented their service at governance meetings. The service

reviewed governance processes every year for each speciality.

All levels of the governance and management function interacted with each other

appropriately. The medical specialities met with the senior team every month. Monthly

governance meetings included: quality board, health & safety meeting, medical pressure ulcer

governance group and staff engagement group. Weekly governance meetings included: medical

modern matron meeting, check and challenge, resource panel. Every other month the trust also

had a health and safety committee meeting.

We reviewed the last three sets of minutes for the quality board and found actions were

reviewed regularly, serious incidents, mortality and morbidity, complaints and the risk

register were discussed. The service had good governance processes for serious incidents. We

reviewed the last three sets of minutes for the serious incident review panel. The meeting was

attended by senior staff from medicine division including: the director of safety, the deputy medical

director and the divisional risk manager. The minutes showed evidence of detailed discussion

about the level of harm caused by the incident and actions for further investigation.

Staff we spoke with were clear about their roles and understood what and for whom they were

accountable.


Systems for identifying and manging risks were not always effective. Risks were not

always graded, mitigated and reviewed appropriately. While senior leaders described a clear

risk management process, it was not clear the service reviewed risks regularly. The risk register

sent to us did not include dates of when staff reviewed risks. There was no clear audit trail of when

staff added or removed risks from the risk register. Senior leaders told us, and we saw from

meeting minutes, that the medical division risk register was reviewed at monthly quality board

meetings. However, this was not clear from what was recorded on the risk register.


Risks were not always graded appropriately. The trust graded risks: risks up to grade eight

were reviewed by matrons, risks between eight and 12 were reviewed at medicine division level

and risks graded above 12 were reviewed at a corporate level. A risk about the ‘risk of harm to

patients as a result of delay in receiving essential, required cardiac interventions’ was only graded

as 9 at the time of inspection so was monitored at cardiology speciality meetings rather than

having more senior oversight of the risk.

The service did not always mitigate risks effectively. The medical division risk register had

mitigating actions for most, but not all recorded risks. For example, the risk ‘the risk of death or

long term clinical harm to patients delayed due to lack of capacity for follow up appointments to

occur within recommended intervals’ had no mitigating actions recorded and the risk score was 9.

Where mitigating actions were recorded the service had assessed 49 out of 87 recorded risks had

incomplete controls.

There were not sufficient arrangements to ensure safety in the event of a fire requiring

evacuation from wards. Across both hospital sites, evacuation plans had been drawn up in

conjunction with the local fire service which showed wards would first be evacuated sideways into

neighbouring bays and wards. However, at Cheltenham General hospital we saw there was no

plans or equipment available to allow staff to evacuate immobile or bed bound patients down

staircases. On Rendcomb ward, staff understood their local fire response plan, however did not

know how they would move patients down stairs if needed. Rendcomb ward was located at the

end of the building, so had no additional space or adjoining wards to allow further sideways

evacuation. We raised this with senior managers and during a follow up visit, staff told us there

were plans to practice fire evacuation procedures the following Monday. Senior staff informed us

fire plans were being reviewed and evacuation equipment for moving mattresses was on order.

Following the inspection, the trust produced an action plan which stated they planned to review the

current policy of not having fire evacuation chairs on the ward.


The trust collected, analysed, managed and used information well to support all its

activities, using secure electronic systems with security safeguards. Staff had a good

understanding of performance, quality and safety. Data around performance, quality and safety

were discussed at governance meetings.

A medical division performance dashboard was produced every month for executive

review. The dashboard included data on: incidents, falls, pressure ulcers and hospital acquired

infections. Data on referral to treatment times and typing backlogs was included in the data

produced for monthly executive review meetings.

All staff had access to the trust intranet and could use it to access the information they

needed such as policies and procedures. The site management team had access to real time

data on bed occupancy and patient discharges to enable them to manage patient flow effectively.

The site management team completed an electronic report each day, known as the ‘sitrep’ which

identified the status of the hospital and provided information on the number of patients admitted,

outlying patients, staffing and escalation beds in use. All staff could access the trust intranet for

information on the status of the hospital each day.

Engagement

The trust engaged well with patients, the public and local organisations to plan and

manage appropriate services. The trust engaged well with staff most of the time.


The medicine clinical division collected information about patients’ and relatives’

experiences of care. Staff encouraged patients to complete the friends and family test when they

were discharged, and this data was reviewed by the trust board.

The service encouraged patients and those close to them to provide feedback about their

care. We saw ‘you said, we did’ information displayed on the wards. For example, the trust

introduced open visiting times between 9am and 9pm, following feedback that patients’ visitors

wanted more flexibility.

Some staff were not always actively or effectively engaged so their views were reflected in

the planning and delivery of services. For example, staff from one team described changes to

their service being proposed, which they heard about unofficially before being consulted with.

Staff had regular ward meetings. The regularity of ward meetings varied from weekly to every

six weeks. Some wards kept ward meeting minutes. Some wards told us staff were too busy to

have regular ward meetings. As an alternative to a ward meeting, ward managers shared

messages with staff at daily safety briefs, emailed important updates and kept a printed file of

updates in a staff communal area.

The trust engaged well with local partners about mental health services. The trust had an

enhanced care collaborative for mental health, dementia, delirium and learning disability which the

safeguarding team were involved in. The trust acknowledged challenges of supporting patients

who were intravenous drug users and has developed good working relations with the local drug

and alcohol service.


The trust was committed to improving services by learning from when things went wrong,

promoting training, research and innovation. The trust had a well-developed quality

improvement programme staff at all levels were engaged with. Staff could gain bronze, silver or

gold awards from the trust quality improvement academy depending on how much time they

invested in quality improvement training and projects. Quality improvement work included

participation in research projects and recognised accreditation schemes. Quality improvement was

discussed at monthly quality board meetings.

The oncology practice development team at Cheltenham General hospital were doing a

research project into the use of closed administration systems for the delivery of

chemotherapy. Staff explained, when preparing chemotherapy delivery sets (the intravenous

equipment used to get the chemotherapy medicines into the patient), staff risked exposure to

potentially harmful vapours from the medicine. The project aimed to see if using of a different

closed delivery system would reduce the amount of vapours staff were exposed to.

The trust had an internal nursing assessment accreditation scheme (NAAS) to review the

safety and quality of care on medical wards. Staff were positive about the accreditation

scheme. On ward 4A at Gloucestershire Royal Hospital, senior nurses had created an action plan

following the ward accreditation visit which was displayed in the staff room. Staff had signed up to

focus on tasks in the action plan to improve patient safety and experience on the ward.

On ward 9A at Gloucestershire Royal hospital, a doctor was involved in a quality

improvement project about over-diagnosis of UTI infections. The trust encouraged staff to

develop quality improvement projects. For example, on Snowshill ward (gastroenterology) at

Cheltenham General hospital, the senior sister was piloting a ‘patient contract for the management


of substance misuse.’ The aim of the contract was to improve the way staff supported and

managed the safety of patients who left the ward at their own risk.

The trust had a strong focus on patient safety. Senior nurses were involved in NHS patient safety

collaboratives for falls prevention, pressure ulcer prevention and infection control.


Surgery


Surgical services provided by Gloucestershire Hospitals NHS Foundation Trust are carried out mostly at two hospital sites; Gloucestershire Royal Hospital and Cheltenham General Hospital. The services are managed at both hospital sites by the surgical division. Day theatre is also provided at Cirencester, Stroud and Tewkesbury Hospitals. The surgical division consists of six service lines:

Trauma and Orthopaedics; trauma, orthopaedics and orthotics. Head and Neck; oral maxillofacial, ears nose and throat, orthodontics, and audiology. Ophthalmology; ophthalmology, orthoptics, optometry, diabetic retinal screening and

medical photography. General Surgery; urology, breast, vascular, upper gastrointestinal, colorectal, bariatric,

urology and abdominal aortic aneurysm screening. Theatres; theatres and day surgery. Anaesthetics; anaesthetics, chronic and acute pain, pre-assessment, acute care

response and critical care. Both Gloucestershire Royal hospital and Cheltenham General hospital provide emergency, elective and day case surgery. The trust is in the process of reviewing and changing the reconfiguration of sites to provide an urgent and emergency centre at Gloucestershire Royal Hospital, and a planned elective site at Cheltenham General Hospital. Currently all trauma surgery is now completed at Gloucestershire, with elective orthopaedic at Cheltenham General Hospital. There are 15 wards with a total of 309 beds, and 26 theatres, across both sites. At the Cheltenham General Hospital there are five surgical wards and a day surgery unit, with a total of 131 inpatient beds. There are 12 theatres which are located in three different areas of the hospital. At Gloucestershire Royal Hospital there are seven wards with a total of 154 beds. There are 14 theatres, and these are all located in the main theatre suite. (Source: Acute Routine Provider Information Request (RPIR) –P2 Sites) The trust had 48,373 surgical admissions from March 2017 to February 2018. Emergency

admissions accounted for 12,091 (25%), 28,126 (58%) were day case, and the remaining 8,156

(17%) were elective. On a single day there are approximately 192 day surgery cases and 147

inpatient operations.


As part of this unannounced inspection we reviewed trust wide processes, systems and leadership

for the surgical division. We inspected at the two sites Gloucestershire Royal Hospital, and


At Gloucestershire Royal Hospital we visited the following areas:

Main theatres

Day surgery and surgical admissions

Ward 2a - trauma and spinal unit

Ward 3a - trauma and neck of femur

Ward 3b - emergency medical and trauma


Ward 5a - emergency surgery

Gallery ward – a ward for patients who are medically fit for discharge but awaiting ongoing

care packages

Discharge lounge

Pre-assessment

At Cheltenham General Hospital we visited the following areas:

Orthopaedic theatres

General theatres

Kemerton day surgery and surgical admissions

Bibury ward - colorectal, gynae oncology and general surgery

Alstone ward - elective orthopaedics

Dixton ward - elective orthopaedics

Hazelton – orthopaedic admissions

Guiting ward - vascular surgery

Prescott ward - colorectal and major pelvic resection

Pre-assessment unit

We spoke with approximately 130 staff across Gloucestershire Royal Hospital and Cheltenham

General Hospital about the surgical service. This included; surgical division leaders, nursing staff

on theatres and in wards, medical staff to include junior doctors through to consultant level, allied

health professionals, and hospital support staff. Some staff worked across both sites, while others

worked just at one site.

We spoke with seven patients at Gloucestershire Royal Hospital about the care and treatment

they had received and saw feedback from surveys and thankyou cards. We reviewed 12 patient

records.

We spoke with five patients at Cheltenham General Hospital about the care and treatment they

had received, saw feedback from surveys and thankyou cards. We reviewed six patient records.

Data was requested during this inspection which was reviewed and analysed, some of which is

referenced within this report.


Mandatory training

The service provided mandatory training in key skills to all staff, however this was still not meeting trust targets. Mandatory training compliance was mostly meeting or just below trust targets for nursing staff. For medical staff performance was not always meeting trust targets. Staff told us they had access to the training required for their role. Staff participated in a

range of mandatory training as seen in the tables below, delivered both face to face and via

electronic learning. Nursing staff and doctors commented they were made aware of when

mandatory training was due. We saw lists of nursing staff members with outstanding training

requirements posted in ward staff rooms. Senior staff were aware of which staff members required

updated training and helped to manage this process.

We were told by staff across all wards how mandatory training, in recognition and treatment of mental health needs, was provided. This was mostly in the form of e-learning.


Mandatory training completion rates The trust set a target of 90% for completion of mandatory training. The training courses cover the compliance for the 12 months up to June 2018. Trust level In surgery the 90% target was met for six of the 10 mandatory training modules for which qualified nursing staff were eligible. A breakdown of compliance for mandatory training courses as of June 2018 at trust level for qualified nursing staff in surgery is shown below:


trained Eligible

staff Completion

rate Trust

Target Met

(Yes/No)










Conflict Resolution 589 695 85% 90% No In surgery the 90% target was met for one of the nine mandatory training modules for which medical staff were eligible. A breakdown of compliance for mandatory training courses as of June 2018 at trust level for medical staff in surgery is shown below:


trained Eligible

staff Completion

rate Trust

Target Met

(Yes/No)









Conflict Resolution 285 375 76% 90% No Cheltenham General Hospital surgery department At Cheltenham General Hospital surgery department, the 90% target was met for eight of the 10 mandatory training modules for which qualified nursing staff were eligible. A breakdown of compliance for mandatory training courses as of June 2018 for qualified nursing staff in the surgery department at Cheltenham General Hospital is shown below:


trained Eligible

staff Completion

rate Trust

Target Met

(Yes/No)









Manual Handling - People 269 297 91% 90% Yes


Conflict Resolution 259 297 87% 90% No At Cheltenham General Hospital surgery department, the 90% target was met for none of the nine mandatory training modules for which medical staff were eligible. A breakdown of compliance for mandatory training courses as of June 2018 for medical staff in the surgery department at Cheltenham General Hospital is shown below:


trained Eligible

staff Completion

rate Trust

Target Met

(Yes/No)









Manual Handling - Object 5 13 38% 90% No Gloucestershire Royal Hospital surgery department At Gloucestershire Royal Hospital surgery department, the 90% target was met for six of the 10 mandatory training modules for which qualified nursing staff were eligible. A breakdown of compliance for mandatory training courses as of June 2018 for qualified nursing staff in the surgery department at Gloucestershire Royal Hospital is shown below:


trained Eligible

staff Completion

rate Trust

Target Met

(Yes/No)










Conflict Resolution 250 306 82% 90% No At Gloucestershire Royal Hospital surgery department, the 90% target was met for none of the nine mandatory training modules for which medical staff were eligible. A breakdown of compliance for mandatory training courses as of June 2018 for medical staff in the surgery


department at Gloucestershire Royal Hospital is shown below:


trained Eligible

staff Completion

rate Trust

Target Met

(Yes/No)









Conflict Resolution 4 19 21% 90% No (Source: Routine Provider Information Request (RPIR) – Training tab)

Safeguarding

Staff understood how to protect patients from abuse and the service worked with other agencies to do so. There were clear safeguarding processes and systems which staff followed. Staff could confidently tell us about these processes if they identified a safeguarding concern and were able to access the trust safeguarding team for support. Safeguarding training compliance was just below trust targets for nursing staff and was not meeting trust targets for medical staff. Medical staff safeguarding training needed improvement for both level one and level two adults and children training. Safeguarding training completion rates The trust set a target of 90% for completion of safeguarding training. The training courses cover the compliance for the 12 months up to June 2018. Trust level In surgery the 90% target was met for one of the five safeguarding training modules for which qualified nursing staff were eligible. A breakdown of compliance for safeguarding training courses as of June 2018 at trust level for qualified nursing staff in surgery is shown below:


trained Eligible

staff Completion

rate Trust

Target Met

(Yes/No)





Safeguarding Children (Level 3) 0 1 0% 90% No In surgery the 90% target was met for one of the five safeguarding training modules for which medical staff were eligible. A breakdown of compliance for safeguarding training courses as of June 2018 at trust level for medical staff in surgery is shown below:


trained Eligible

staff Completion

rate Trust

Target Met

(Yes/No)






Safeguarding Children (Level 1) 261 375 70% 90% No Cheltenham General Hospital surgery department At Cheltenham General Hospital surgery department, the 90% target was met for two of the four safeguarding training modules for which qualified nursing staff were eligible. A breakdown of compliance for safeguarding training courses as of June 2018 for qualified nursing staff in the surgery department at Cheltenham General Hospital is shown below:


trained Eligible

staff Completion

rate Trust

Target Met

(Yes/No)




Safeguarding Children (Level 1) 253 297 85% 90% No At Cheltenham General Hospital surgery department, the 90% target was met for none of the four safeguarding training modules for which medical staff were eligible. A breakdown of compliance for safeguarding training courses as of June 2018 for medical staff in the surgery department at Cheltenham General Hospital is shown below:


trained Eligible

staff Completion

rate Trust

Target Met

(Yes/No)




Safeguarding Adults (Level 2) 4 13 31% 90% No Gloucestershire Royal Hospital surgery department At Gloucestershire Royal Hospital surgery department, the 90% target was met for one of the four safeguarding training modules for which qualified nursing staff were eligible. A breakdown of compliance for safeguarding training courses as of June 2018 for qualified nursing staff in the surgery department at Gloucestershire Royal Hospital is shown below:


trained Eligible

staff Completion

rate Trust

Target Met

(Yes/No)




Safeguarding Adults (Level 2) 261 306 85% 90% No At Gloucestershire Royal Hospital surgery department, the 90% target was met for none of the four safeguarding training modules for which medical staff were eligible. A breakdown of compliance for safeguarding training courses as of June 2018 for medical staff in the surgery department at Gloucestershire Royal Hospital is shown below:



trained Eligible

staff Completion

rate Trust

Target Met

(Yes/No)




Safeguarding Adults (Level 2) 4 19 21% 90% No (Source: Routine Provider Information Request (RPIR) – Training tab)


Standards of cleanliness and hygiene were maintained across both sites and there were systems to protect people from healthcare associated infections. However, some wards at Gloucestershire Royal Hospital were less visibly clean. Staff followed good infection control practice. When observing care and treatment being

provided to patients by nursing staff we saw hands were washed regularly and appropriate

personal protective equipment was used. Staff labelled equipment with dated ‘I am clean’ stickers

following cleaning, which assured staff that the equipment was clean and ready to use.

At both hospitals there was a plentiful supply of hand sanitiser available at ward entrances,

with signs to remind staff and visitors to wash their hands on entering and leaving the

wards. Some of these were empty, however this was mitigated by the number available. When

staff were informed of the empty sanitisers they were restocked in a timely manner.

The trust undertook hand hygiene audits for surgical theatres and wards across the period

of April to September 2018. Nursing staff scored above 97% in each month audited, health care

assistants scored above 95% in each month audited, and medical staff scored the lowest at above

86%.

The surgical wards managed infectious patients well. We saw wards had enough side rooms to isolate infectious patients. Side rooms were labelled to warn staff and visitors of the infection risk. Reminders about safe management of infections were displayed on wards. We saw an example in one patient record of a patient with clostridium difficile, they were reviewed by the medical team and there was input from the infection control nurse to ensure this patient’s infection and the risk of infection to others was being managed appropriately. The surgical wards used fabric curtains around patient bedsides and we were informed

these were changed by the linen department on a six-week rolling basis. Staff could request

a change of curtains if they became soiled, and we observed a member of staff requesting this

and saw they were replaced in a timely manner.

The service had infection prevention and control (IPC) link nurses and resource folders in all of the

surgical wards and departments for staff to refer to.

In Gloucestershire Royal Hospital the cleaning was split out between domestic staff and

health care assistants. Some wards had a domestic allocated to a ward. In Cheltenham General

Hospital domestic cleaners were contracted to clean floors and empty bins, however the day to

day cleaning was carried out by nursing and health care assistant staff.

In terms of cleaning, hospital areas were designated into categories that were determined

by risk, for example theatres were classified as very high risk. This meant the cleaning of this

area was audited on a weekly basis and in order to pass a score of 95% or above had to be

obtained. We saw evidence of this being monitored by the facilities department. If the score was


not obtained the information was fed back to the appropriate team so that the issue could be

rectified.

All elective patients were required to be screened for Methicillin Resistant Staphylococcus

Aureus (MRSA). Data was still not being routinely collected for MRSA screening, however we

were told spot check audits were completed. We were not provided with clear evidence to

demonstrate this. However, within patient records we saw evidence patients were screen pre-

operatively for MRSA. The trust monitored the incidence of infections such as MRSA, Clostridium

Difficile (C. Diff), Methicillin Sensitive Staphylococcus Aureus (MSSA) and Escherichia Coli (E.

Coli).

Surgical Site Infections

There were improvements with surgical site infection (SSI) rates, although orthopaedic

surgery was still performing worse when compared nationally, and therefore called an

outlier.

Data for trauma and orthopaedics showed:

Performance for January to March 2018 showed the overall SSI for hip replacements was

2% (9.1% at Gloucestershire Royal Hospital and 1% at Cheltenham General Hospital)

representing five cases, this was higher than the national average of 1%.

Performance for October to December 2017 showed the overall SSI for knee replacements

was 1.7% (0% at Gloucestershire Royal Hospital and 1.7% at Cheltenham General

Hospital) representing four cases, this was higher than the national average of 1.3%.

Performance for October to December 2017 showed the overall SSI for reduction long bone

was 1.7% this was slightly higher than the national average of 1.5%.

Performance for October to December 2017 showed the overall SSI for spinal surgery was

7.6%, representing five cases, this was higher than the national average of 1.7%. At the

time of inspection this was performing better than the national average.

Performance for October to December 2017 showed the overall SSI for repair of neck of

femur was 0.5%, representing one case, which was better than the national average of

1.3%.

Data for breast surgery showed:

Performance for January to March 2018 showed the overall SSI for breast surgery was

3.4% (2.5% at Gloucestershire Royal Hospital and 3.8% at Cheltenham General Hospital),

representing seven cases, this was slightly higher than the national average of 3.1%.

At the time of the inspection the trust told us they were now performing well and better

than the national average for spinal, gastric, large and small bowel, and breast surgery.

Surveillance data from Public Health England evidenced this.

Surgical site infections were monitored by the infection prevention control surgical site

infection surveillance staff. Our previous inspection identified the trust was an outlier for surgical

site infection for replacement of hips and knees, and spinal surgery. The theatres were part of a

collaboration to reduce their surgical site infections to include: patient warming, warming of

intravenous fluids, patients washing prior to surgery and wound management. A leaflet had been

developed to provide education to patients around surgical site infections, and what they can do to

reduce the risk. MSSA screening was due to commence at the trust to identify the presence of this


bacteria and treat patients, to help reduce the risk of infection. This was in addition to the already

regularly screened MRSA. The trust had also invested in a software package which would allow

them to monitor surgical site infections more easily and produce monthly reports for surgeons, so

they are aware of their performance.

Blood Stream Infections

There was work looking at reducing bloodstream infection (BSI) associated with parenteral

nutrition (PN) administered via a central venous catheter (CVC). The project involved

recording the BSI rate each month and the number of PN administered each month to allow for a

comparison of monthly BSI rates. A Root Cause Analysis tool (RCA) was developed to investigate

each BSI. Findings from each RCA were reported to the relevant ward manager to highlight areas

which could be improved and to guide action planning on the ward. Pop up ward-based teaching

sessions for nursing staff were used to highlight the risk factors for patients developing a BSI and

clarify best practice for management of CVC and PN. We spoke with a parenteral nutrition

intravenous specialist nurse who confirmed they worked across both hospital sites. We observed

them visiting a patient and feeding back relevant information to nursing staff. At the end of July

2018, the team reported a 49.6% reduction in BSI rates since the start of January 2018.


The design, maintenance and use of facilities were adequate to meet the needs of patients,

although some of the wards were old and displayed signs of wear and tear, which risked

impacting infection control. Some theatres and wards were cluttered due to the lack of space,

which added an infection control and health and safety risk in these environments.

Storage of equipment across wards did not always promote a safe environment. At

Cheltenham General Hospital on Guiting ward we noticed two beds in the corridor leading to the

fire exit. While this did not completely block access the fire escape could be compromised. There

was further equipment including hoists, bedside tables and drip stands which impeded access to a

bathroom. At Gloucestershire Royal Hospital on ward 2A the patient toilet was obstructed, and we

also found ward equipment was poorly stored in a room, which would make it difficult for staff to

access other equipment needed.

The layout of wards in both Gloucestershire Royal Hospital and Cheltenham General

Hospital meant there were some areas which were not as visible to nursing staff as others.

However, this was mitigated by having staff stations in bays and managing the acuity level of

patients in these areas.

Staff managed clinical waste in line with trust policy. Sharps were disposed of safely in

correctly assembled and dated sharps disposal boxes. Waste bins were appropriately colour

coded for the appropriate waste disposal method and we noted bins were regularly emptied by

domestic staff during our inspection.

Generally, equipment was easily accessible from both Cheltenham and Gloucestershire

hospital. Staff reported the clinical sterile services department store was responsive and

equipment was generally received within two to three hours.

Staff in Guiting ward in Cheltenham General Hospital reported the wheelchairs for patients

who had below the knee leg amputations were not suitable for use. This was connected to

the issue of stump boards. Guiting ward also reported there were problems when issuing

equipment to patients that came from the Wiltshire area. This was connected to commissioning

issues and area coverage.


On Alstone ward the chlorine disinfectant was not held securely. This posed a risk patients

could access this harmful disinfectant. We raised this with the nurse in charge who told us they

would ensure this was locked away. This was raised with the Trust during inspection feedback and

since the inspection they have put actions in place to ensure this does not occur.

Checking procedures were not consistently followed, or appropriate escalation was not

completed. There were some omissions with equipment checks in theatres at Gloucestershire

Royal Hospital. The anaesthetic machine checks in theatre two were not signed as checked daily.

New resuscitation trolleys had been implemented on the wards, these were tamper evident.

We randomly reviewed trolleys and checking procedures, at times the daily checking procedures

were incomplete. There was an example where a daily check was ticked for oxygen cylinders, yet

the oxygen cylinder was empty. On Bibury ward at Cheltenham General Hospital they were

waiting for the delivery of a new trolley. The current trolley was covered by a blue cloth with no

signage to show this was the resuscitation trolley. This trolley was not sealed and there was no

oxygen available. The trust was informed following our inspection how resuscitation trolleys were

not being checked according to policy, and action plan for this included ensuring checks were

completed and an audit programme of compliance was implemented.

In theatres we observed good support of sharps management and swab control and count.

A stock control system had been introduced in theatres, this enabled equipment to be in the right

place in a timely manner.

There were central sterile service departments at both sites. They had their British standards

institution certificate registration and were audited to ensure compliance. There were no concerns

with quality system or audits.

Holes in sterilised surgical packs was a theme across both theatres. At Cheltenham General

Hospital the clinical sterile services department were trialling a vacuum pack to avoid shearing

during transport. Space was limited in theatres at Gloucestershire Royal Hospital, this meant sets

were sometimes piled three high.

At Cheltenham General Hospital in theatre there was only one radiographer and equipment

which meant availability was an issue. We were told there was funding for an additional

machine, but arrangements for staffing were unconfirmed.

The difficult airway trolley pictures did not match correctly within Gloucestershire Royal

Hospital theatre trolleys. This meant there was a risk in an emergency the incorrect equipment

would be selected or cause delays.


Risk Assessments

Staff completed and updated risk assessments for each patient. These were assessed,

monitored and managed on a day to day basis so patients were supported to stay safe.

An enhanced care risk assessment must be done within 12 hours of admission to each new ward;

this reviews the patients risks of falls, risk of patient getting up unaided or attempting to leave the

ward, episodes of increasing confusion/delirium/dementia, and other clinical risk. A score was then

calculated to determine the level of observation and possible interventions.

Venous thromboembolism (VTE) risk assessments were completed on admission. A second

assessment after 24 hours was not always recorded as complete. We saw this in four of the 18

patient records we reviewed, two in each site. We saw that patients were having VTE assessments


that were being reviewed and that they were prescribed therapy appropriate to their needs. This

was either injections, tablets or compression stockings.

Deteriorating Patients

There were processes to recognise and respond to a deteriorating patient. The national early

warning score (NEWS 2) was used to record patient observations whereby a scoring system

allows early identification and appropriate escalation. Staff were confident in this process and how

to escalate. The acute care response team were accessible and would be called if NEWS was

greater than seven, and informed if NEWS greater than five or three in one parameter. The

completion and accuracy of NEWS 2 was audited monthly by review of a random sample of five

records from each ward. Feedback was provided to the ward on their compliance with NEWS 2.

We saw examples of audits completed for both hospital sites surgical wards and identified areas

for improvement for completeness of observations.

The trust was proactively using simulation to recognise and respond to the deteriorating

patient. Trust wide there was a simulation suite which was used to act out scenarios where a

patient deteriorates. Four larger simulations were completed each year to test the system and

identify any learning. Simulation exercises were also being completed on the wards, to include

surgical wards, which were simulated relevant to the area, and the resuscitation team were looking

to do one ward a week. Theatres did a lot of simulation and difficult airway work in recovery.

The anaesthetic team were responsible for managing difficult airways. Standard airway

trolleys were updated and rolled out across theatres to ensure they were all the same. Following

an incident with a cardiac or respiratory arrest on a ward an airway team was assigned to be

bleeped to respond in these instances.

Sepsis

A sepsis care bundle was used for the management of patients with presumed or

confirmed sepsis. The trust had a sepsis screening and action tool, this was in use on the

surgical wards which gave staff clear direction on escalating patients where there was a suspected

infection. The sepsis six care bundle outlines six actions, to be undertaken within one hour, for

early management of sepsis.

The trust was not able to provide sepsis performance data specifically for surgical wards,

and therefore were unable to see how specific areas were performing. The trust was meeting

targets for sepsis screening (target above 90%) and sepsis treatment within timescales (target

above 50%) when reviewing trust wide performance data. The trust initiated a case study into

improving initial sepsis management. This found that the trust was at 85% – 95% compliance with

delivering antibiotics within an hour, indicating further work was required. It should be noted this

figure was for both emergency department and inpatients, therefore the actual position of surgery

patients is not known and cannot be separated out.

Safety Huddles and Handovers

There were arrangements for handovers to ensure important information was shared to keep

patients safe.

Board rounds were undertaken each morning, seven days a week, led by a senior clinical decision

maker.

Nursing staff completed handovers between each shift to ensure their colleagues were well

informed of the patients they would be caring for. Some wards completed a safety huddle prior


to the handover, where all patients were discussed in terms of risks and important information.

This also allowed important messages to be shared with staff. However, not all wards had

implemented this.

Patient handovers for internal ward transfers was managed by completing a patient

handover checklist. We observed one internal ward transfer for a patient and saw it was handled

in a safe manner, with the appropriate documentation completed.

In Cheltenham General Hospital we observed a patient handover from recovery to the ward.

This was detailed and ensured all important information was shared with the receiving ward using

the patient records to ensure no information was missed.

In theatres a ‘team ten’ meeting was held every morning and attended by theatre staff. We

attended the team ten meeting at Gloucestershire Royal Hospital. This was well attended by a

range of staff, to also include; risk manager, clinical sterile services department, site managers,

recovery, and theatre leads. We were provided an example of how the risk manager would raise

any incident trends identified, for example an increase in sharps incidents, and see if staff had any

thoughts about why this was happening.

World Health Organisation Five Steps to Saver Surgery

The World Health Organisation (WHO) surgical safety checklist was used in theatres and a

positive culture of using this process and challenging anyone who is not compliant was

starting to embed. This was despite the introduction and publication of the safety checklist in

2008. This WHO surgical safety checklist included a surgical safety operating list briefing,

discussing all patients on the list both before the list starts and at the end of the list. It also

included individual patient anaesthetic sign in, knife to skin time out and sign out.

We reviewed the completion of the WHO surgical safety checklist sign in, time out and sign

out paper record for patients post their surgery. These were mostly complete, although there

was no printed name next to the signatures and the date of the operation was not always

recorded.

We observed the WHO surgical safety checklist in practice in four theatres (two at each

site), each was performed well. Staff acknowledged there was room for improvement regarding

engagement with the WHO surgical safety checklist and consistency across all lists.

The trust audited their performance monthly to provide information regarding the rate of

compliance of the WHO surgical safety checklist. This now included an observational study

and data was broken down by hospital site and by specialty. We reviewed the August 2018 report

covering Monday 23 July to Friday 3 August, where 120 observations were completed. The report

provided a detailed breakdown and identified areas of compliance and non-compliance. There was

an action plan for any areas where there were recommendations for improvement. There were

also areas which were not considered current practice, yet were included on the audit form, we

were told the WHO checklist may be adapted to include these areas. For example, surgeon

checks to prepare for anticipated blood loss or anaesthetic checks confirming patients ASA grade

(physical status classification for fitness for surgery).

Mental Health

Staff had access to 24/7 mental health liaison and specialist mental health support if were concerned about risks associated with a patient’s mental health. Nurses on the wards had a limited understanding of how to assess somebody who was at risk of suicide or self-harm. Assessing risks was generally seen as a role for the doctors to carry out. Staff demonstrated an awareness of the risks associated with suicidal people and told us they


cared for at risk patients in beds that are easily observable and would never place somebody in a side room. They told us they would use their own trained health care assistants to deliver enhanced care or use bank or agency staff to deliver this. Staff required some additional support to manage patients living with mental health needs safely. For example, in Cheltenham General Hospital a patient living with a diagnosis of dementia became agitated and aggressive. Lorazepam (a sedative) was written for this patient as a means of chemical restraint. The violence and aggression team were in attendance and intramuscular lorazepam administered. There was no record of whether the patient agreed or whether medication was administered against their will. The incident was poorly recorded in their patient record. Following this incident, no capacity assessment was completed or consideration of legal framework to manage the aggression. No PRN (when necessary) prescription was written up. The sister and matron confirmed they would incident report and investigate, and we raised our concerns with the trust. We raised our concerns with the trust, they reviewed the timeline of events and identified key issues for learning. The adult safeguarding team undertook two short training sessions on capacity assessments and delirium on the 6th and 7th November.

Outliers

Medical patients would regularly outlay on surgical wards. Outliers are patients who are

admitted to a ward which is not the correct ward to meet their care and treatment needs. Outlying

patients had a raised profile and where necessary were prioritised to be moved to their correct

specialist ward. There were clear arrangements for doctor and consultant support for these

patients, although staff on surgical wards reported difficulties in accessing these teams or delays

when not an emergency. Some staff raised concerns about the suitability of medical patients on

their surgical wards, and this impacted on their staffing.

Planned Surgery

Patients who were planned for surgery were reviewed pre-operatively to confirm their

fitness for surgery. This was completed via a telephone, or nurse or anaesthetic led face to face

appointment.

Pre-operative assessment clinics were held at both Cheltenham General and

Gloucestershire Royal hospitals. Patients attended a pre-operative assessment clinic prior to

surgery where their general health and suitability for surgery was assessed. Any patient identified

as a potential anaesthetic risk or other concern was reviewed by an anaesthetist. We observed

two pre-assessment appointments, one at each hospital. The patient was taken through an

operation assessment and management proforma to identify any areas where the patient was at

increased surgical risk. This process also helped to limit the risk of a cancellation of a theatre slot.

There were no stress tests used in pre-admission. Patients were risk stratified on a scoring system

and determined whether suitable for surgery.

Emergency Surgery

American Society of Anaesthesiologist (ASA) standards and guidelines were used to

assess patients on admission. A scoring system was completed for emergency patients to

calculate the risk prediction in surgery in terms of morbidity and mortality.

At Gloucestershire Royal Hospital there was a 24-hour emergency theatre, and an

emergency co-ordinator would ensure patients were operated on in a timely manner. At

Cheltenham General Hospital, which did not operate an emergency department overnight, there

was an 18-hour emergency theatre, however an on-call team would be available if needed.

Nurse staffing

Staffing on wards was regularly at minimum staffing levels rather than at funded


establishment, particularly at night times. We saw evidence of this when reviewing rotas on surgical wards. Matrons confirmed staff were working at the minimum level of establishment and on occasion just below establishment. We were unable to identify any impact on safety of the low staffing numbers, as staff ensured the safety of their patients. However, this was detrimental to the well-being of staff who regularly felt they were overworked, exhausted and not always getting enough breaks. Agency staff was not regularly used as rotas were filled using the bank or backfilling of own staff. We raised our concerns around staffing with the trust, as an action the trust was reviewing staffing for surgical wards, this had been written and presented to the surgical divisional board. A strategic safe staffing review was also completed and presented to a joint Quality and Performance Committee and People and Organisational Development Committee. Nursing staffing levels was reviewed twice a year using the evidence-based Keith Hurst (April 2002) staffing tool. The planned staffing levels were then used by ward managers and sisters to arrange staffing rotas. It was not always clear how wards were using patient acuity to help plan their staffing. Some wards spoke of new acuity tools they were trialling, while others did not use acuity to plan their staffing. A nursing acuity tool had been built into the roster system, however this was not yet embedded across wards and units. This aimed to see in real time the acuity on wards and allow managers to visualise workload and move staff accordingly. A daily call was held to review surgical ward staffing, chaired by a matron or ward manager, each ward manager dialled in to provide an update on their ward's staffing numbers. Any patients requiring enhanced care were discussed and reviewed, and any staffing gaps were identified. Unfilled gaps were escalated to the chief nurse for surgery. We saw an example completed daily staffing call for 9 October 2018 covering both hospital sites. The trust moved staff according to patient needs across the surgical wards and hospitals when required. This was not popular with staff although they did acknowledge it was necessary to ensure safety for patients. Staff who moved specialities stated this was difficult in terms of meeting patient needs. The trust was trying to recruit to vacant nursing posts. Divisional recruitment events had taken place to recruit additional healthcare assistants and band 5 nurses. There were several healthcare assistants due to start across surgical wards. Theatre staffing was arranged using the Association for Perioperative Practice guidelines. Staffing levels in theatres were not a concern amongst staff. There was a low use of agency staff in theatres. Each theatre had assigned two scrub nurses to include one scrub and one runner, one healthcare assistant and one anaesthetic qualified nurse or operating department practitioners. The trust has reported their staffing numbers below for the May 2018.

Location Planned staff – WTE Actual staff – WTE Fill rate

Gloucestershire Royal Hospital 322.22 269.18 84%

Cheltenham General Hospital 287.84 264.45 92% These figures had changed from March 2017 for Gloucestershire Royal Hospital where the fill rate was previously 93% and therefore there was now more vacancies. Cheltenham General Hospital was still at 92%. (Source: Routine Provider Information Request (RPIR) –Total staff tab) Vacancy rates As of May 2018, the trust reported a vacancy rate of 10.9% in surgery;


Cheltenham General Hospital surgery department: 8.1% Gloucestershire Royal Hospital surgery department: 16.5%

The trust did not report an overall target vacancy rate. (Source: Routine Provider Information Request (RPIR) – Vacancy tab) Turnover rates From June 2017 to May 2018, the trust reported a turnover rate of 10.4% in surgery. Cheltenham General Hospital surgery department: 8.2% Gloucestershire Royal Hospital surgery department: 12.9% (Source: Routine Provider Information Request (RPIR) – Turnover tab) Sickness rates From June 2017 to May 2018, the trust reported a sickness rate of 4.2% in surgery, which was higher than the trust’s overall target sickness rate of 3.5%: Cheltenham General Hospital surgery department: 4.3% Gloucestershire Royal Hospital surgery department: 4.6% (Source: Routine Provider Information Request (RPIR) – Sickness tab) Bank and agency staff usage The trust did not provide total shifts including substantive staff, so we are unable to provide a percentage usage for bank and agency, however a breakdown of total shifts from July 2017 to June 2018 for surgery is shown below:

Bank shifts Agency shifts Unfilled shifts

11,939 3,217 3,616 (Source: Routine Provider Information Request (RPIR) – Bank and Agency tab)

Medical staffing

There were gaps in rotas for non-consultant medical staffing. We were unable to confirm if the surgical division had enough medical staff to deliver a safe and effective service. We requested from the trust data to show their medical staffing, however this was only provided for one specialty. It was therefore not clear if this information is available, or where the gaps were. From talking with medical staff, overall across all surgical specialties medical staffing was said to be good in the day time, although sometimes staff felt stretched out of hours. Nursing staff spoke positively about the support they received from their surgical medical team. However, there were sometimes difficulties in accessing the medicine medical team, for outlying patients on surgical wards or day surgery unit when it was not an emergency. It was confirmed consultant ward rounds were completed every morning, to include weekends. Medical and anaesthetist cover was provided outside of normal working hours on a rota basis. Junior and middle grade doctors and locums provided out of hours medical care to patients on the surgical wards during out of hours periods. There was also on-call cover


provided by consultant surgeons who could be contacted by telephone. We were informed of difficulties recruiting to staff grades and therefore some gaps in rotas. Reviewing the surgical division risk register the risks around staffing included:

Risk to finance of employment of agency staff as unable to recruit to junior doctor posts. Risk to workforce well-being.

The trust was establishing and increasing numbers of advanced nurse practitioners and physician assistant roles to help mitigate any gaps in the rota. Existing junior doctors where possible were covering gaps and consultants were acting down. Three orthogeriatricians were available to include weekend cover. The trust was performing well with fracture neck of femur patients being seen by an orthogeriatrician within 72 hours. Staffing skill mix The skill mix for medical staffing was comparable to the England average. From June 2017 to May 2018, the proportion of consultant staff reported to be working at the trust was higher than the England average and the proportion of junior (foundation year 1-2) staff was the same. Staffing skill mix for whole time equivalent staff working at Gloucestershire Hospitals NHS Foundation Trust This

Trust England average

Consultant 52% 49% Middle career^ 13% 11% Registrar Group~ 23% 29% Junior* 11% 11%

^ Middle Career = At least 3 years at SHO or a higher grade within their chosen specialty ~ Registrar Group = Specialist Registrar (StR) 1-6 * Junior = Foundation Year 1-2

(Source: NHS Digital Workforce Statistics)

Vacancy rates As of May 2018, the trust reported a vacancy rate of 4.7% in surgery: Cheltenham General Hospital surgery department: 20.8% We were not provided with data for Gloucestershire Royal Hospital surgery department



(Source: Routine Provider Information Request (RPIR) – Vacancy tab) Turnover rates From June 2017 to May 2018, the trust reported a turnover rate of 4% in surgery: (Source: Routine Provider Information Request (RPIR) – Turnover tab) Sickness rates From June 2017 to May 2018, the trust reported a sickness rate of 1.9% in surgery. Cheltenham General Hospital surgery department: 1.9% Gloucestershire Royal Hospital surgery department: 1.7%

This is compared to the trust’s overall target sickness rate of 3.5% (Source: Routine Provider Information Request (RPIR) – Sickness tab) Bank and locum staff usage The trust did not provide total shifts including substantive staff, so we are unable to provide a percentage usage for bank and locum staff however a breakdown of total shifts from July 2017 to June 2018 for surgery is shown below: The breakdown is shown in the table below.

Staff level Bank shifts Locum shifts Unfilled shifts

Doctors in training 345 887 72

Middle grades 663 106 19

Consultant 0 192 0

(Source: Routine Provider Information Request (RPIR) - Medical agency locum tab)

Records

Staff kept records of patients’ care and treatment, however records were not always well

organised and were sometimes incomplete. The record arrangements were messy, which did

not enable quick and easy access to information, and there was lots of loose paper. Recorded

entries were not always signed and dated, this was typically medical entries which did not have

the doctors name clearly printed with signature and registration number. There were examples

where risk assessments were not fully complete, for example completion of lying and standing

blood pressure on a falls risk assessment and bed rails risk assessment.

There was secure storage for patient notes on wards and units. In our previous inspection we

found there was a lack of secure storage for patient notes, which meant unauthorised people

could access confidential records. During this inspection patient records were kept securely within

lockable units. There was one exception on ward 2B at Gloucestershire Royal Hospital, during a

visit to the ward it was noticed the trolley containing the medical records of patients was not


locked, and there were three sets of notes at a nurse station which were left unattended. This

meant patient confidential information was not protected and could be accessed by unauthorised

people.

In Gloucestershire Royal Hospital, therapy staff on two wards reported problems with lack

of appropriate information contained in the notes. This resulted in wasted time tracking down

the consultant or doctor to understand what rehabilitation work the patient should undertake.

In the Cheltenham General Hospital pre-assessment unit, it was noted there was a problem

obtaining the patient’s notes in time for their pre-assessment appointment. Staff stated they

often carried out the assessment without sight of the notes. This meant duplication of work and a

risk information could be missed. When the notes did arrive, the nurse had to go through both

records to ensure that the patient had informed the nurse of all relevant pre-existing conditions

and past procedures.

Discharge was communicated to GPs by sending care summaries on discharge, this

ensured the continuity of care in the community. The discharge summaries we reviewed were

sent in a timely manner.

Medicines

The service aimed to follow best practice when prescribing, giving, recording and storing

medicines. However, there were a few exceptions.

Medical gas oxygen cylinders were not being stored securely across surgical wards and

theatres on both sites. We identified on six wards oxygen cylinders were not stored in secure

racking, some were stored in treatment rooms, while others were stored in the wards main corridors

which were accessible to patients and visitors. In theatres at Gloucestershire Royal Hospital

cylinders were not fixed securely. There was a risk the cylinders could fall over and injure staff,

visitors or patients, or an explosion hazard. Oxygen cylinders were also not always separated by full

and empty, which caused a risk in an emergency an empty cylinder would be picked up.

Medicines were stored securely in locked treatment rooms and were only accessible to

authorised staff. There was one exception on ward 3A at Gloucestershire Royal Hospital where

the code to the medicines room was written on a whiteboard outside the door. This was raised with

the senior sister on the ward.

There were some instances where medicines were not stored or disposed of correctly. At

Gloucestershire Royal Hospital we found out of date injections in the locked cupboards. Expiry date

checks were recorded as having been completed in September. Expiry dates seen included

09/2017, 05/2016 and 01/2018. This was raised with the senior sister and the ward pharmacist. At

Cheltenham General Hospital on Kemerton day surgery unit we reviewed medicines and found a

bottle of Oramorph Oral Solution opened but not labelled with the date of opening. This medicine

needs to be discarded if not used within three months. We raised this with the unit’s sister.

Controlled drugs (medicines that require extra checks and special storage arrangements

because of their potential for misuse) were stored securely and were regularly checked.

Controlled Drugs balance checks were completed twice a day by two nurses. Random balance

check completed and physical stock matched registers. There were some examples where daily

checks were missed across both sites on surgical wards and in theatres. On Bibury ward at


Cheltenham General Hospital we did identify some patients own controlled drugs were still present

after discharge and the trust’s procedure had not always been followed.

Fridge temperature records showed medicines were being kept at appropriate temperatures.

Daily fridge temperatures were checked, however when out of range no escalation was evident. We

saw examples of this on wards and in theatres at both sites. Following our inspection, the trust action

plan showed they were ensuring the policy for fridge temperature checks was robust and clear, and

ward teams were being reminded of processes. An audit programme was being developed to ensure

compliance against standards.

Staff were not always recording in the prescription record when PRN (as required)

medication had been offered to patients. When reviewing prescription records it was not

recorded to show a clear auditable trail, sometimes a note was made in the patient record.

Staff said pharmacy support was effective and they were accessible both for wards and theatres.

Medicine incidents and errors were incident reported. We were given an example how

changes had been made to their practice following a recent incident.

Antibiotics were reviewed periodically in line with trust’s Antibiotic Stewardship policy.

Incidents

Staff knew how to report incidents, however there was variation across the sites about the

level of shared learning. Incidents were reported electronically and then investigated by a

relevant senior member of staff. Investigation reports were shared with specialty governance

groups and action plans monitored.

In Gloucestershire Royal Hospital most staff were aware of the incident reporting process.

It was noted by several staff members there was no feedback from incidents despite ticking the

feedback box. One staff member stated how not receiving feedback was a disincentive for filling

out an incident form.

In Cheltenham General Hospital staff were aware of the incident reporting process. Staff

said that they received feedback from incidents.

Staff understood the term duty of candour and could provide examples of how they have or would apply this. Duty of Candour, Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 was introduced in November 2014. This Regulation requires a provider to be open and transparent with a patient or other relevant person when things go wrong in relation to their care and the patient suffers harm or could suffer harm which falls into defined thresholds. Never Events There were some risks to the likelihood of never events which were not well managed. During the inspection we saw operating lists which did not clearly state the operating side. Increasing the risk of never events. We also saw an example of an incorrect operating list at Cheltenham General Hospital. We saw good practice where the surgeon during the team briefing asked for an incident to be reported where the patient side was omitted, and to reprint the list which was in the wrong order. The trust was reviewing their incidence of never events across specialties and how they could reduce these happening. Never events are serious patient safety incidents that should


not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event. The surgical division had reported four new never events between August 2017 and July 2018 and identified one further never event from a previous surgery. All never events were fully investigated and discussed to identify learning and changes to practice. Previously not all staff had been aware of the never events and the learning across the surgical division. Posters were now displayed in theatres, so all theatre staff could see the type of never events which had occurred across the surgical division and any outcomes and learning. Prior to this, there were two never events in theatres with wrong sized bearing for knee replacements. One incident had occurred in January 2016 and was identified when a patient presented in March 2017, and one occurred in April 2017 and was detected at the time of surgery. A briefing was shared with staff following initial review of events. From August 2017 to July 2018, the trust reported five incidents classified as never events for surgery.

Medication incident of a wrong route drug administration in recovery (August 2017). A safety briefing was shared with staff with recommendations for shared learning.

An initial incision was made on the wrong finger (August 2017). This was not incident reported by the surgeon or theatre team and was only identified following a complaint three months after the incident. A safety briefing was shared with staff around site marking, WHO safety briefing, pausing prior to knife to skin, and all incidents must be reported.

Cataract surgery incorrect lens implanted. (November 2017) Lessons and recommendations were identified and evident within the clinical governance meeting minutes.

Historic incident, whereby in April 2018 it was identified a wrong ureteric stent had been removed in previous surgery.

Patient had an anaesthetic block on the wrong side prior to their orthopaedic surgery, and therefore their surgery was postponed (March 2018)

(Source: Strategic Executive Information System (STEIS)) To address the never events in theatres the trust commissioned an independent review of theatres culture and human factors and could demonstrate learning and improvements. This review focussed on clinical standards, patient safety and organisational culture, and was completed in April 2018. Following this review measures were implemented to further develop a culture of safety. This included; team 10 safety briefs held daily, message of the week to share learning in theatres, plans for human factors and simulation training, and quality improvement projects.


Breakdown of serious incidents reported to STEIS In accordance with the Serious Incident Framework 2015, the trust reported 10 serious incidents (SIs) in surgery which met the reporting criteria set by NHS England from August 2017 to July 2018. The types of incident reported were:

Three surgical/invasive procedure incidents (30% of total incidents). Two slips/trips/falls (20% of total incidents). One sub-optimal care of the deteriorating patient (10% of total incidents). One medication incident (10% of total incidents). Three were pending review (30% of total incidents).


We saw evidence learning from serious incidents was shared in safety briefings across

both sites and discussed in clinical governance meetings. There was an example of a bulletin

'learning from recent clinical incidents' which was shared with staff. An incident occurred where a

sick surgical patient on a ward subsequently died. Although staff were aware and managing the

patient with the doctors overnight, the consultant was unaware of the sickest patient, who should

have been seen immediately on their ward round. Staff were reminded of their daily board/ward

round guidance 'SORT' - Sick patients, Out today or tomorrow, Rest of the patients, To come in,

and also escalation processes to acute care response team and consultants.

Safety thermometer

The service used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors. Managers used this to improve the service. Surgical wards were aware of and reported their safety thermometer performance. The Safety Thermometer is used to record the prevalence of patient harms and to provide immediate information and analysis for frontline teams to monitor their performance in delivering harm free care. Measurement at the frontline is intended to focus attention on patient harms and their elimination. Data collection takes place one day each month – a suggested date for data collection is given but wards can change this. Data must be submitted within 10 days of suggested data collection date. Data from the Patient Safety Thermometer showed that the trust reported 32 new pressure ulcers, 20 falls with harm and 40 new catheter urinary tract infections from July 2017 to July 2018


for surgery. Prevalence rate (number of patients per 100 surveyed) of pressure ulcers, falls and catheter urinary tract infections at Gloucestershire Hospitals NHS Foundation Trust

1

Total Pressure ulcers (32)

2

Total Falls (20)

3

Total CUTIs (40)

1 Pressure ulcers levels 2, 3 and 4 2 Falls with harm levels 3 to 6 3 Catheter acquired urinary tract infection level 3 only

(Source: NHS Digital)

A surgical pressure ulcer governance group was held monthly. Ward managers and sisters

presented cases and the root cause analysis completed.

We were provided with examples of how changes had been made as a result of

performance. Ward 3A (trauma and neck of femur ward), at Gloucestershire Royal Hospital, had

identified a number of pressure sores, they were provided with education on dressings and all

patients were now turned four hourly, even at night. Ward 3A was now using the skin bundle used

in critical care.

Staff on both sites told us they had access to equipment to help reduce patient harm. For

example, pressure relieving mattresses to reduce the incidence of pressure sores, hi-low beds,

seat sensors and use of non-slip socks to reduce the incidence of falls. We saw these in use

across the wards during our visit.



The surgical service provided care and treatment based on national guidance and evidence

of its effectiveness. National sources including; the National Institute for Health and Care


Excellence (NICE) guidance, Royal College Surgeons, and Association for Perioperative Practice

(AfPP), were followed for surgical care and best practice.

Sepsis screening and management was done effectively, in line with National guidance.

Sepsis tools were used to help identify and manage patients with sepsis.

Patients were assessed for venous thromboembolism (VTE) and risk of bleeding within 24

hours of their admission, in line with NICE guidance. If at risk of VTE patients were offered

VTE prophylaxis. This was recorded in patient prescription records.

The trust was one of a few trusts in the UK offering partial knee replacement surgery as a

day case at Cheltenham General Hospital and had been recognised nationally by the

Getting It Right First Time team. This day case pathway was introduced 12 months ago in this

trust by a consultant orthopaedic surgeon and consultant anaesthetist. This was being performed

at Cheltenham General Elective Orthopaedic Unit, working alongside the multidisciplinary team.

Surgical techniques for partial knee replacements and methods of pain relief using ultrasound

guided nerve blocks were being used. This enabled patients to mobilise early and be discharged

the same day to recover at home. Results showed seven out of ten patients who had the day case

pathway went home on the day of surgery.

Staff discussed psychological and emotional needs of patients as part of handover. Staff

described an awareness of the risk of depression in their patients and the impact this could have

on rehabilitation. We observed one staff handover meeting in Gloucestershire hospital between

nurse and therapy team. The psychological and emotional needs of the patients were discussed.

However, in Cheltenham General Hospital on Guiting ward staff were concerned patients

undergoing amputations were not offered psychological support as a matter of course and that

instead it had to be requested on a case by case basis.


Staff gave patients enough food and drink to meet their needs and improve their health.

They used special feeding and hydration techniques when necessary. The service made

adjustments for patients’ religious, cultural and other preferences.

Staff used the Malnutrition Universal Screening Tool (MUST) to assess patients nutritional

and hydration needs. MUST is a five-step screening tool to identify adults, who are

malnourished, at risk of malnutrition or obese. Any patient that scored highly on this tool was

referred to the dietician team. We saw evidence MUST was completed for patients and they were

weighed weekly.

Staff reviewed and monitored patient hydration. All patients we saw during our inspection had

access to water jugs. We saw hydration records were contained and completed within patient

notes.

We observed domestic staff and healthcare assistants offering patients hot and cold drinks

during our inspection. All patients we spoke with stated they were offered a choice of food and

refreshments where it was clinically safe to do so.

Nutrition assistants had been employed on hip fracture wards at Gloucestershire Royal Hospital, with an aim to reduce patient length of stay and mortality. This was introduced based on studies which had suggested benefits of employing nutritional assistants. The nutrition assistants aimed to promote an extra 500 calories of food intake per day for patients and improve ward culture around nutrition. The nutrition assistant role included; encouraging and assisting patients to eat, ensuring MUST scores and weekly weights were recorded, increase positive mealtime experiences, help with menu choices, provide extra snacks, hold Tuesday tea parties, and ensure early referrals to dieticians. The ward results where this had been implemented


showed 80% of patients were offered extra snacks of 200 calories and 68% of patients accepted their snacks. MUST scores were recorded in 25 more patients when compared to previous data without nutrition assistants. The length of stay also reduced to 1.5 days and 30-day mortality from 10% to 6.5%. Although length of stay and mortality are multifactorial, better nutrition may have played a role in improving this.

Patients who were due to attend surgery on the same day were nil by mouth. However,

where specialties did not stagger admissions to the day surgery and admissions unit’s patients

were nil by mouth longer than necessary. This happened at both Gloucestershire Royal Hospital

and Cheltenham General Hospital. We were told staggered admissions was being reviewed as

part of the theatre transformation project. We spoke with staff and patients on Hazleton ward in

Cheltenham General Hospital. Staff commented how elective patients sometimes had a long wait

for surgery, which depending on the time the patients was nil by mouth could be uncomfortable for

the patient. We confirmed with one patient they had been waiting 8.5 hours for their procedure.

There was also a kitchen on Hazleton ward where food was prepared for another ward. For

patients that are nil by mouth the smell of food being prepared could be considered to be unfair.

Staff told us they ensured patients had water up until the point they were no longer allowed and

reviewed their eating and drinking if there were changes to the operation list.

Pain relief

Staff assessed and monitored patients regularly to see if they were in pain. They supported

those unable to communicate using suitable assessment tools and gave additional pain relief to

ease pain.

Staff managed pain relief well. The trust had a nurse led pain team who were nurse prescribers,

this meant they could prescribe certain medication. The wards reported this team was visible and

responsive. All staff members spoke highly of this team. We saw the pain team helping to manage

complex patients on wards at both Gloucestershire Royal and Cheltenham General Hospital.

Pain relief was discussed at pre-operative assessment appointments with patients, patients were

given the opportunity to indicate their preferred post-operative pain relief, for example patient-

controlled analgesia.

Staff asked patients about their pain during ward ‘intentional rounding’. We observed two

patients being asked about their pain during these rounds. Patients told us pain relieving

medication was brought promptly when requested.

We observed medication rounds at both Gloucestershire Royal Hospital and Cheltenham General

Hospital and saw patients were offered pain medications.

The abbey scale tool was used to assess pain for patients who were not able to

communicate verbally. This tool used facial pictures to help patients decide what was most

relevant to them. When reviewing one patient’s record we saw evidence this had been used.

Patient outcomes

The surgical division participated in both national and local audits to monitor people’s care

and treatment outcomes and compare with other similar services. Reviewing data for audits,

the trust was generally performing well or as expected when benchmarked nationally. There was

improved mortality across the trust relating to surgery.

There were 101 registered surgical division audits and quality improvement projects across the

surgical specialties.


Relative risk of readmission Trust level From May 2017 to April 2018, all patients at the trust had a lower expected risk of readmission for elective admissions when compared to the England average. Of the top three specialties by admission, all had a lower expected risk of readmission for elective admissions when compared to the England average. Elective Admissions – Trust Level

Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 is represents the opposite. Top three specialties for specific trust based on count of activity

All patients at the trust had a lower expected risk of readmission for non-elective admissions when compared to the England average. Of the top three specialties by admission, all had a lower expected risk of readmission for non-elective admissions when compared to the England average. Non-Elective Admissions – Trust Level

Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 is represents the opposite. Top three specialties for specific trust based on count of activity

(Source: Hospital Episode Statistics - HES - Readmissions (01/05/2017 - 30/04/2018)) Gloucestershire Royal Hospital From May 2017 to April 2018, all patients at Gloucestershire Royal Hospital had a lower expected risk of readmission for elective admissions when compared to the England average. Of the top three specialties by admission both ear, nose and throat (ENT) patients and trauma and orthopaedics patients at Gloucestershire Royal Hospital had a higher expected risk of readmission for elective admissions when compared to the England average.


Elective Admissions - Gloucestershire Royal Hospital

Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 is represents the opposite. Top three specialties for specific site based on count of activity

All patients at Gloucestershire Royal Hospital had a lower expected risk of readmission for non-elective admissions when compared to the England average. Of the top three specialties by admission, only ear, nose and throat (ENT) patients at Gloucestershire Royal Hospital had a higher expected risk of readmission for non-elective admissions when compared to the England average. Non-Elective Admissions - Gloucestershire Royal Hospital


Cheltenham General Hospital From May 2017 to April 2018, all patients at Cheltenham General Hospital had a lower expected risk of readmission for elective admissions when compared to the England average. Of the top three specialties by admission, all patients at Cheltenham General Hospital had a lower expected risk of readmission for elective admissions when compared to the England average. Elective Admissions - Cheltenham General Hospital

Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive


finding, as this means there were fewer observed readmissions than expected. A value above 100 is represents the opposite. Top three specialties for specific site based on count of activity

All patients at Cheltenham General Hospital had a lower expected risk of readmission for non-elective admissions when compared to the England average. Of the top three specialties by admission, all patients at Cheltenham General Hospital had a lower expected risk of readmission for non-elective admissions when compared to the England average. Non-Elective Admissions - Cheltenham General Hospital


(Source: Hospital Episode Statistics) National Hip Fracture Database There had been a reduction in the fractured neck of femur trust mortality, which at the time of inspection we were told the current 2018 figure was at 4.8%, this data was not for the complete year and was not yet validated on the national hip fracture database. National Hip Fracture Database (Cheltenham General Hospital) In the 2017 National Hip Fracture Audit, the risk-adjusted 30-day mortality rate was 8.3% which was within the expected range. The 2016 figure was 8.8%. The proportion of patients having surgery on the day of or day after admission was 64.3%, which failed to meet the national standard of 85%. This was within the bottom 25% of trusts. The 2016 figure was 71.8%. The perioperative medical assessment rate was 94.9%, which failed to meet the national standard of 100%. This was within the middle 50% of trusts. The 2016 figure was 89.7%. The proportion of patients not developing pressure ulcers was 98.2%, which failed to meet the national standard of 100%. This was within the middle 50% of trusts. The 2016 figure was 99.1%. The length of stay was 16 days, which falls within the top 25% of trusts. The 2016 figure was 13 days. (Source: National Hip Fracture Database 2017) National Hip Fracture Database (Gloucestershire Royal Hospital)


In the 2017 National Hip Fracture Audit, the risk-adjusted 30-day mortality rate was 6.7% which was within the expected range. The 2016 figure was 10.4%. The proportion of patients having surgery on the day of or day after admission was 77.9%, which failed to meet the national standard of 85%. This was within the middle 50% of trusts. The 2016 figure was 73.2%. The perioperative medical assessment rate was 97.7%, which failed to meet the national standard of 100%. This was within the top 25% of trusts. The 2016 figure was 96.4%. The proportion of patients not developing pressure ulcers was 98.7%, which failed to meet the national standard of 100%. This was within the top 25% of trusts. The 2016 figure was 98.4%. The length of stay was 16.5 days, which falls within the top 25% of trusts. The 2016 figure was 16.6 days. (Source: National Hip Fracture Database 2017) Bowel Cancer Audit In the 2017 Bowel Cancer Audit, 62.7% of patients undergoing a major resection had a post-operative length of stay greater than five days. This was better than the national aggregate. The 2016 figure was 68.4%. The risk-adjusted 90-day post-operative mortality rate was 1.6% which was within the expected range. The 2016 figure was 2.2%. The risk-adjusted 2-year post-operative mortality rate was 16.6% which was within the expected range. The 2016 figure was 19.9%. The risk-adjusted 30-day unplanned readmission rate was 10.8% which was within the expected range. The 2016 figure was not reported. The risk-adjusted 18-month temporary stoma rate in rectal cancer patients undergoing major resection was 43.4% which was better than expected. The 2016 figure was 39.2%. (Source: National Bowel Cancer Audit) National Vascular Registry In the 2017 National Vascular Registry (NVR) audit, the trust achieved a risk-adjusted post-operative in-hospital mortality rate of 1.1% for Abdominal Aortic Aneurysms. The 2016 figure was 1.7%. Within Carotid Endarterectomy, the median time from symptom to surgery was 21 days which is worse than the audit aspirational standard of 14 days. The 30-day risk-adjusted mortality and stroke rate was 1.5%, this was within the expected range. (Source: National Vascular Registry) Oesophago-Gastric Cancer National Audit In the 2016 National Oesophago-Gastric Cancer Audit, the age and sex adjusted proportion of patients diagnosed after an emergency admission was 16.1%. Patients


diagnosed after an emergency admission are significantly less likely to be managed with curative intent. The audit recommends that overall rates over 15% could warrant investigation. The 2015 figure was 19%. The 90-day post-operative mortality rate was 5.7%. This was within the expected range. The 2015 rate was 7.9%. The proportion of patients treated with curative intent in the Strategic Clinical Network was 36.7%. This was similar to the national aggregate. This metric is defined at strategic clinical network level; the network can represent several cancer units and specialist centres); the result can therefore be used a marker for the effectiveness of care at network level; better co-operation between hospitals within a network would be expected to produce better results (Source: National Oesophago-Gastric Cancer Audit 2016) National Emergency Laparotomy Audit The trust had formed a quality improvement group to focus on emergency laparotomy across both hospital sites for a period of two years. This coincided with an agreed CQuIN (commissioning for quality and innovation) with the commissioner for 2015-16. In 2012 mortality for the year was 12.7% (90 patients), this had improved significantly and between 2015 and 2018 was 7.5% (53 patients). We reviewed the most up to date validated data from the national emergency laparotomy audit. This data is reported for the year 2016. National Emergency Laparotomy Audit (Cheltenham General Hospital) The national Emergency Laparotomy audit awards three ratings for each indicator. Green ratings indicate performance of over 80%, amber ratings indicate performance between 50% and 80% and red ratings indicate performance under 50%. In the 2016 National Emergency Laparotomy Audit (NELA), Cheltenham General Hospital achieved an amber rating for the crude proportion of cases with pre-operative documentation of risk of death. This was based on 136 cases. The site achieved a green rating for the crude proportion of cases with access to theatres within clinically appropriate time frames. This was based on 101 cases. The site achieved an amber rating for the crude proportion of high-risk cases with a consultant surgeon and anaesthetist present in the theatre. This was based on 83 cases. The site achieved a green rating for the crude proportion of highest-risk cases admitted to critical care post-operatively. This was based on 54 cases. The risk-adjusted 30-day mortality for the site was within the expected range based on 136 cases.

(Source: National Emergency Laparotomy Audit) The trust provided us with more recent data for 1 March 2018 to 31 May 2018 for 47 patients at Cheltenham General Hospital.

The risk of death being assessed and documented before surgery was completed in


91.5% of cases, which was better than the 79.7% national mean. Consultant present in theatre when risk of death greater than or equal to 5% was in 100%

of cases, which was better than the 91.9% national mean. Consultant anaesthetist present in theatre when risk of death greater than or equal to 5%

was 96.8%, which was better than the 89.4% national mean. Admitted to critical care following surgery when risk of death greater than or equal to 5%

was 96.2% which was better than the 78.3% national mean. Admitted to critical care following surgery when risk of death greater than 10% was 100%

which was better than the national mean of 85.8%. National Emergency Laparotomy Audit (Gloucestershire Royal Hospital) The national Emergency Laparotomy audit awards three ratings for each indicator. Green ratings indicate performance of over 80%, amber ratings indicate performance between 50% and 80% and red ratings indicate performance under 50%. In the 2016 National Emergency Laparotomy Audit (NELA), Gloucestershire Royal Hospital achieved an amber rating for the crude proportion of cases with pre-operative documentation of risk of death. This was based on 232 cases. The site achieved a green rating for the crude proportion of cases with access to theatres within clinically appropriate time frames. This was based on 146 cases. The site achieved an amber rating for the crude proportion of high-risk cases with a consultant surgeon and anaesthetist present in the theatre. This was based on 136 cases. The site achieved a green rating for the crude proportion of highest-risk cases admitted to critical care post-operatively. This was based on 100 cases. The risk-adjusted 30-day mortality for the site was within the expected range based on 232 cases.

(Source: National Emergency Laparotomy Audit) The trust provided us with more recent data for 1 March 2018 to 31 May 2018 for 40 patients at Gloucestershire Royal Hospital.

The risk of death being assessed and documented before surgery was 92.5%, which was better than the 79.7% national mean.

Consultant present in theatre when risk of death greater than or equal to 5% was 91.3% of cases, which was better than the 91.9% national mean.

Consultant anaesthetist present in theatre when risk of death greater than or equal to 5% was 78.3%, which was worse than the 89.4% national mean.

Admitted to critical care following surgery when risk of death greater than or equal to 5% was 66.7% which was worse than the 78.3% national mean.

Admitted to critical care following surgery when risk of death greater than 10% was 71.4% which was worse than the national mean of 85.8%.

Patient Reported Outcome Measures In the Patient Reported Outcomes Measures (PROMS) survey, patients are asked whether they feel better or worse after receiving the following operations:


Groin hernias Varicose veins Hip replacements Knee replacements

Proportions of patients who reported an improvement after each procedure can be seen on the right of the graph, whereas proportions of patients reporting that they feel worse can be viewed on the left.

In 2016/17 performance on groin hernias was better than the England average. For Varicose veins, performance was about the same as the England average. For hip replacements, performance was about the same as the England average. For Knee replacements was about the same as the England average. (Source: NHS Digital)

Ophthalmology

The ophthalmology team had been recognised nationally and typically operated on eight

cataracts per operating list. With their overall performance comparing favourably with other UK

units, especially cataract, age-related macular degeneration, and glaucoma services.

Competent staff

The surgical service made sure staff were competent in their roles. Managers appraised staff

work performance and reviewed their competencies.

Competencies for staff were clearly set out and recorded. We reviewed examples of

completed competencies for staff across surgical wards and theatres at both hospital sites.

Competencies completed were dependent on staff role and requirements for their surgical work.

Nursing staff understanding of sepsis was sometimes limited when asking staff to explain

how they would manage a patient suspected of having sepsis, however they were clear on

how they would use the NEWS 2 scores to escalate to doctors or the outreach team.

Although all staff had been trained in identifying the deteriorating patient and escalating to the

medical team or acute care response team.


Staff reported they received an induction process to help orientate them in their new place

of work. We saw examples of a theatre induction booklets for new trust staff and students.

Newly registered staff were provided with support and guidance as part of their one-year

preceptorship (transitioning from a student to a nurse or operating department practitioner). We

saw the induction information for healthcare assistants for the discharge waiting area at

Gloucestershire Royal Hospital. This was a comprehensive induction booklet that was created for

healthcare assistants by the sister in charge as a gap in the induction process was identified and

rectified. However, we spoke with locum medical staff who reported they did not attend an

induction process.

A trust local induction for temporary staff was used for all staff new to the department or

returning to the same department after one year or more. This included bank, agency and staff

permanently relocating from other areas. We saw examples of completed forms for agency staff

working at the time of our inspection on both hospital sites. The form included; checking

identification and nursing registration, then orientation to the ward and important contact details.

We spoke to one agency nurse at Gloucestershire Royal Hospital, although they were orientated

there was difficulties due to staffing numbers for someone to provide time to show them all areas,

and a healthcare assistant completed this rather than the person in charge, but we did not

corroborate this further.

The trust had link practitioners in theatres and wards, who helped ensure best practice. As

part of their role they attended meetings and completed audits and disseminated information to

their teams. Link practitioners included; infection control, tissue viability, learning disabilities,

manual handling, dementia care, and safeguarding.

Staff commented that development and learning opportunities were available however it

was sometimes difficult to attend due to staffing issues. Junior doctors we spoke with stated

there were good training opportunities available at the trust, and there was generally no difficulty

accessing courses and practical learning.

Three student nurses on different surgical wards/units told us they were enjoying their

placements and felt they were receiving good quality teaching. They felt supported and able

to approach mentors or any trained member of staff for advice.

We spoke with staff who had to deal with a violent and aggressive patient. They informed us

how they could contact the violence and aggression team for support.

In theatres audit training days were being developed and run monthly. The practice

development team had oversight of this.

A divisional practice development nurses had been recruited, to start in November 2018, with

plans for development programmes and learning, which will help support staff retention.

Resuscitation training was aligned to the core skills framework. All clinical staff required a

minimal of level two which includes adult and paediatric basic life support. Nurses in acute areas

tended to have intermediate life support, and all foundation two doctors were contractually

expected to have advance life support. The acute care team, who would respond to a cardiac

arrest were all trained in advanced life support.

Appraisal rates Appraisals were falling short of trust targets. However, on most wards and theatres visited we

saw evidence staff had received appraisals or meetings were arranged for staff appraisals. With

exception in the pre-admission units, nursing staff in both Gloucestershire and Cheltenham were


behind in their appraisals due to staffing pressures and the volume of work. This was being

mitigated by training a further staff member so that they could conduct appraisals.

From July 2017 to June 2018, 79% of staff within surgery at the trust received an appraisal compared to a trust target of 90%. At the end of the last financial year (April 2017 to March 2018) this figure was 83%. Staffing group Appraisals

required (YTD)

Appraisals

complete (YTD)

Completion

rate

Qualified Allied Health Professionals

(Qualified AHPs)

32 29 91%

Medical & Dental staff - Hospital 187 168 90%

Other Qualified Scientific, Therapeutic &

Technical staff (Other qualified ST&T)

85 74 87%

Support to ST&T staff 22 18 82%

Qualified nursing & health visiting staff

(Qualified nurses)

741 568 77%

Support to doctors and nursing staff 457 347 76%

NHS infrastructure support 28 21 75%

Qualified Healthcare Scientists 35 22 63%

A site breakdown can be seen below: Cheltenham General Hospital From July 2017 to June 2018, 81% of staff within surgery at Cheltenham General received an appraisal compared to a trust target of 90%. Last financial year (April 2017 to March 2018) 84% had completed an appraisal. The breakdown by staff group can be seen in the table below: Staffing group Appraisals

required (YTD)

Appraisals

complete (YTD)

Completion

rate


Qualified Allied Health Professionals

(Qualified AHPs)

29 26 90%




25 22 88%




(Qualified nurses)

280 220 79%

Gloucestershire Royal Hospital From July 2017 to June 2018, 75% of staff within surgery at Gloucestershire Royal received an appraisal compared to a trust target of 90%. Last financial year (April 2017 to March 2018) 81% had completed an appraisal. The breakdown by staff group can be seen in the table below:


Staffing group Appraisals

required (YTD)

Appraisals

complete (YTD)

Completion

rate



58 50 86%



(Qualified nurses)

376 289 77%




Medical & Dental staff - Hospital 1 0 0%

(Source: Routine Provider Information Request (RPIR) – Appraisal tab)


Staff of different disciplines and roles worked together as a team to benefit patients.

Doctors, nurses, and other healthcare professional supported each other to provide good care.

Effective multidisciplinary team working was evident on all wards, theatres and units, across both

hospital sites. We observed staff working together such as consultants, physiotherapists,

occupational therapists, dieticians, nursing, and medical staff, and saw there was generally good

communication between different staff disciplines. This was also reflected when talking to staff

who positively spoke about multidisciplinary team working and strong working relationships.

The surgery service utilised healthcare professionals such as occupational therapists,

physiotherapists and dieticians, to work together with the nursing and medical teams to

assess, plan and deliver care and treatment to patients. We observed board rounds on the

wards visited that had a multidisciplinary team approach. However, staff on Guiting ward at

Cheltenham General Hospital raised how therapy staff were not included in multidisciplinary team.

Therapy staff told us they were also not able to visit patients’ homes if a patient lived in Wiltshire to

assess rehabilitation needs, due to commissioning arrangements.

Input from the various liaison teams aided the care of patients with additional support

needs. All staff described receiving very good support from the dementia liaison nurses and

learning disability liaison nurses. The psychiatric liaison team was also accessed, and input was

mostly via consultant and other medical staff.

Staff discussed discharge needs with patients, families and carers at pre-admission clinics

and liaised with other services and organisations where appropriate. We were given an

example of this as a husband and wife were both in hospital, wife in Gloucestershire Royal

Hospital and the husband in Cheltenham General Hospital at the same time. The two teams were

communicating to see if they could get a combined package of care for both following discharge.

Seven-day services

Acute and emergency surgical services were available seven days a week at both

Gloucestershire Royal Hospital and Cheltenham General Hospital. However, compliance with

the seven-day standards was not always consistent across specialties and access to diagnostics

was sometimes difficult at weekends and overnight.


At Gloucestershire Royal Hospital there was a 24-hour emergency theatre. At Cheltenham

General Hospital this was only 18 hours, with an on-call arrangement to cover the remaining

hours. This was a recognised risk on the division’s risk register of not being able to provide a 24-

hour emergency theatre.

Staff told us how a shortage of radiologists made it difficult to provide 24-hour cover. There

was still no formal out of hours interventional radiology rota for vascular, urology and gastro

intestinal services. Out of hours was an informal basis with interventional radiologists being called

at home and attending where available. There was a risk to patient safety in providing timely

treatment to patients in an emergency. This was included on the divisional risk register and had

been since our previous inspection. There was currently insufficient interventional radiologists to

provide a sustainable rota. However, the trust told us an interventional radiology service was

established following our inspection on 19 November 2018.

In Cheltenham General Hospital there was no ultrasound available on a weekend. There was

a recent example where a ward had to send their patient to Gloucestershire Royal Hospital to

enable them to access this service. This impacted on patient experience.

The time for first consultant review was generally being achieved. However, ongoing review

by a consultant, twice daily for high dependency patients, or daily for other patients, was not

consistent across the specialties. However, all staff felt they were able to access consultant input if

required.

Access to dietetics and speech and language therapists was sometimes difficult. This was

reported by staff and also when talking to a family member. There was an example of a patient at

Gloucestershire Royal Hospital who had not had input from a speech and language therapist for

six days since referral. Please see the medicine core service evidence appendix for further

comment on the speech and language provision across the trust.

The pain team were available Monday to Friday. At the weekends there was an on-call

anaesthetist and there was a list of any patients with epidurals who required review.

The dementia and learning disability liaison nurses were available Monday to Friday, 9am to 5pm.

The psychiatric liaison team was available 24 hours a day.

Health promotion

Health promotion was considered throughout the patient’s care with the surgical service.

The surgical service aimed to support patients to be as fit as possible for surgery by providing

information and guidance to educate patients ahead of their elective surgery. For example, eating

the right food, stopping smoking, and reducing alcohol. Following surgery patients were provided

with information and health guidance to improve the speed of their recovery and their well-being in

the future.


Staff demonstrated a limited understanding of the Mental Capacity Act. We observed capacity assessments which were not decision specific. Capacity assessments were being completed by junior doctors who had met somebody for the first time, as opposed to nurses who may know the patient better. The mental capacity act states the best person to carry out an assessment is the person who knows the individual best. Deprivation of liberty safeguards (DoLS) applications did not adequately describe the


treatment proposed or restrictions to be placed upon somebody. This was a trust wide issue identified during our inspection when reviewing patient DoLS applications. Mental health act administration was subject to a service level agreement. We found the level of scrutiny was not adequate due to issues identified. Staff did not have a clear understanding of a patients’ rights or the correct paperwork for the mental health act. In Gloucestershire Royal Hospital we saw an example of a DoLS and an attempted detention on a section 5(2), this is a temporary hold of an informal or voluntary service user while waiting for an assessment to be arranged under the Mental Health Act. However, we found incorrect paperwork was used. We also found inappropriate restraint used. A section 2 was put in place, detaining a patient in hospital for 28 days for assessment and treatment, but the patient did not have it recorded that their rights had been read to them, as legally required. We raised our concerns with the trust. As an action the timeline was reviewed and key issues for learning were identified. We were told a section policy had been approved and would be uploaded to the policy website. A check system was going to be implemented to ensure patients with an active section were referred to the mental health team to ensure compliance with the Mental Health Act. A new trust e-learning training package was going live on 5th November 2018. Appropriate consent forms were completed for patients for their surgery. This included detail of any risks to surgery. We reviewed 14 consent forms, which were mostly complete. We did identify three consent forms at Cheltenham General Hospital were signed prior to the day of surgery and were not signed by a healthcare professional on the day of surgery to confirm consent. We also saw omissions of a printed patient name. We saw evidence resuscitation decisions had been considered in three of the 18 patient records reviewed and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms had been completed. However, for one patient this was not completed despite the patient requiring admission to critical care and critical care input post-surgery. Training received by staff informs them on an expectation for DNACPRs to be completed for emergency admissions, deteriorating patients or those meeting the acute care team criteria, and patients discharged from critical care unit. However, this was not always followed. There was no audit to review the compliance of this. Mental Capacity Act and Deprivation of Liberty training completion The trust reported that from July 2017 to June 2018 Mental Capacity Act (MCA) training was completed by 92% of staff in surgical care compared to the trust target of 90%. The breakdown by site was as follows:

Cheltenham General surgery department: 96% Gloucestershire Royal surgery department: 91%

There was no specific training module for deprivation of liberty. (Source: Routine Provider Information Request (RPIR) – Training tab)



Compassionate care

All staff were committed to providing excellent care to their patients. There was a patient

centred culture and staff preserved patient privacy and dignity. Patients spoke positively

about all staff and described the care as being good and responsive to their needs. Wards

received thank you cards and positive feedback from friends and family.

We spoke to seven patients at Gloucestershire Royal Hospital, comments about the staff and care

included:

“truly covering my needs”

“could not do enough for me.”

One relative told us how all staff had been remarkable and were loving, dedicated and

encouraging. However, it was evident they were tired as there was not enough staff, and there

were delays in being seen because of this.

We spoke to five patients at Cheltenham General Hospital and reviewed ‘thank you’ cards,

comments about the staff and care included:

“very professional and caring”

“professional, competent and caring attention”

“team of smiling faces, all gave me care, respect and with dignity, while carrying out their

duties”

We observed staff introducing themselves to patients who had been admitted to the ward following surgery. Patients were welcomed and informed of important information, for example facilities available to them and access to the call bell. Staff were aware of patients’ care needs and communicated in an appropriate friendly and

professional manner.

On Guiting ward, at Cheltenham General Hospital, we were informed there were often

patients from the homeless population. A member of the nursing staff used to wash the

clothes for these patients so that they would have something clean to wear on discharge.

Nurses on Prescott ward, at Cheltenham General Hospital, informed us that patients

undergoing breast surgery were given heart shaped cushions to fit under the arm that were

knitted by volunteers. We observed an expressive and friendly doctor on Prescott ward

engaging with the patients and keeping them informed of the plans for their care, treatment or

discharge arrangements.

At Gloucestershire Royal Hospital, on Gallery ward, therapy staff ran singing and exercise

classes for patients. On Ward 3A therapy staff also arranged breakfast club and exercise

classes for patients. We observed one breakfast club where staff encouraged patients to make

some tea and toast in a kitchen environment, so they could be assessed on their ability to look

after themselves on discharge.

All staff spoke in a non-judgemental way towards patients with mental health needs and learning disabilities, although understanding of complexities was lacking. This was


particularly evident in how the trust supported people with learning disabilities to access care across the surgical service. Friends and Family test performance

The Friends and Family Test response rate for surgery at Gloucestershire Hospitals NHS Foundation Trust was 24% which was similar to the England average of 26% from June 2018 to June 2018. A breakdown of response rate by site can be viewed below. Friends and family test response rate at Gloucestershire Hospitals NHS Foundation Trust, by site.

Note - The formatting above is conditional formatting which colours cells on a grading from highest to lowest, to aid in seeing quickly where scores are high or low. Colours do not imply the passing or failing of any national standard.


(Source: NHS England Friends and Family Test)



The surgical service was reviewing and making changes to the way they delivered services

across the two hospital sites. The long-term strategy for the surgical service was to model a hot

(Gloucestershire Royal Hospital) and cold (Cheltenham General Hospital) site. This would split

emergency and urgent care (hot) from planned surgery (cold). The aim was for higher productivity

in theatres and more efficient use of beds for planned surgery, avoiding the risk of cancelled

operations from emergency admissions by having a protected elective centre. A pilot was running

for trauma and orthopaedics, +due to go to the health overview and scrutiny committee in March

2019. A similar configuration for gastrointestinal surgery was in the process of going through panel

before it was also piloted.

The day surgery unit at Gloucestershire Royal Hospital had ‘ring fenced’ beds and

therefore was now not being regularly used for outlying inpatients and was only used for

surgical day case patients. Prior to June 2018 the day surgery unit was used as an escalation

area to bed patients waiting for beds, up to 22 emergency admission patients would be bedded on

the unit almost daily through winter, which impacted on the elective work stream. From 1 June

2018 the day surgery unit had been ring fenced and no patients had been bedded on the unit

preserving the elective workstream. As a result, the trust had seen a reduction in the number of

complaints, an increase in positive friends and family test scores and patient feedback, and a

reduction in the number of temporary staff used.

The Gloucestershire Royal Hospital day surgery unit was still not a suitable environment,

and this was acknowledged by the leadership team. The area was cramped and did not

promote privacy and dignity to patients, there was limited areas to be in private to discuss

sensitive information. It also required a refurbishment to make it more appealing to welcome

patients and improve their overall experience. For example, the waiting room was an old bay.

However, there were plans to improve the environment.

The day surgery unit at Cheltenham General Hospital had not been ring fenced and

therefore at times of escalation, was being used for inpatients. There were still concerns

about domestic cover for cleaning and food when this was being used.

The signage across both sites did not help patients to access and find services easily. At

Gloucestershire Royal Hospital there was confusion amongst inspectors in accessing the day

surgery unit and surgical admissions unit, which were now combined within the day surgery unit.

The signage across the hospital had not been updated correctly to reflect this. Furthermore, when

reviewing patient booking letters the letter did not clearly state the level or block where the unit

was located to help patients to access the service. We also found Cheltenham General Hospital to

be a confusing layout, although helped by volunteers and staff guiding patients and visitors to the

correct area. Again, when accessing the day surgery unit, the arrow signage for Kemerton and

Chedworth was not clear. The arrow for one area pointed one way then changed to the other

direction once you had walked down the corridor. We raised this as a concern with the trust who

put an action plan in place to review the current approach to signage and identify immediate

shortfalls.


In Gloucestershire Royal Hospital patients arriving in the day surgery unit were receiving

different information on their appointment letter. This included differences in the detail of

advice and information provided. We saw examples of letters, some letters included appointment

time rather than informing the patient this was their arrival time and there may be a long wait for

their surgery. There was also a patient on the day of our inspection whose letter said they were

having their colorectal surgery under local anaesthetic. This caused the patient distress thinking

they were having local anaesthetic for major surgery, when in fact they were having general

anaesthetic. It was hoped the communication to patients would be streamlined and improved

when centralising the booking team and systems. As part of the trust’s post inspection action plan

they reviewed the different versions of patient letters inviting patients to the day surgery unit.

There were not many staggered admissions for elective patients receiving surgery. This

meant some patients were frustrated that they were expected to arrive in the morning for an

afternoon operation. It impacted on their personal and working life. This was a cause for many

complaints for the day surgery units. This was being reviewed by the leadership team and theatre

general manager.

Quality improvements have helped to improve the service being delivered to patients. For example, at Gloucestershire Royal Hospital day surgery unit a programme has been followed to step into patient’s shoes and see care through their eyes. This was decided to be completed based on negative feedback from patients about their waits and experiences. As part of the programme staff met patients at the hospital entrance and follow them through their care. Outcomes included improving the hospital signage, ensuring patients in the waiting room are interacted with and included on nursing staff lists, and adding a television in the waiting room. Another example at Cheltenham General Hospital in their day surgery unit was the use of an alert checklist from pre-assessment to place in the patient notes. This included clearly recording and alerting of any hearing or sight impairment, food intolerance, plus size patients, mobility aids or concerns, purple butterfly (identifying patients living with a diagnosis of dementia or learning disabilities), bariatric bed or additional equipment, falls risk or allergies. This enabled theatres, recovery and the ward to all be alerted so they could prepare ahead of receiving the patient. Staff told us this has helped improve communication between departments. Average length of stay Trust Level – elective patients From June 2017 to May 2018, the average length of stay for all elective patients at the trust was 3.4 days, which is lower than the England average of 3.9 days. For the top three specialties by admission:

Trauma and orthopaedics elective patients at the trust was 3.7 days, which is similar to the England average of 3.8 days.

Urology elective patients at the trust was 3.2 days, which is higher than the England average of 2.5 days.

Ear, nose and throat (ENT) elective patients at the trust was 1.6 days, which is lower than the England average of 2.0 days.

Elective Average Length of Stay – Trust Level



Trust Level – non-elective patients The average length of stay for all non-elective patients at the trust was 4.8 days, which is similar to the England average of 4.9 days. For the top three specialties by admission:

General surgery non-elective patients at the trust was 3.8 days, which is the same as the England average of 3.8 days.

Trauma and orthopaedics non-elective patients at the trust was 7.3 days, which is lower than the England average of 8.7 days.

Urology non-elective patients at the trust was 3.7 days, which is higher than the England average of 2.9 days.

Non-Elective Average Length of Stay – Trust Level


Gloucestershire Royal Hospital - elective patients From June 2017 to May 2018 the average length of stay for all elective patients at Gloucestershire Royal Hospital was 2.9 days, which is lower than the England average of 3.9 days. For the top three specialties by admission:

Trauma and orthopaedics elective patients at Gloucestershire Royal Hospital was 3.0 days, which is lower than the England average of 3.8 days.

Ear, nose and throat (ENT) elective patients at Gloucestershire Royal Hospital was 1.6 days, which is lower than the England average of 2.0 days.

Upper Gastrointestinal Surgery elective patients at Gloucestershire Royal Hospital was 2.9 days, which is lower than the England average of 4.7 days.

Elective Average Length of Stay - Gloucestershire Royal Hospital



Gloucestershire Royal Hospital - non-elective patients The average length of stay for all non-elective patients at Gloucestershire Royal Hospital was 4.8 days, which is similar to the England average of 4.9 days. For the top three specialties by admission:

General surgery non-elective patients at Gloucestershire Royal Hospital was 3.7 days, which is similar to the England average of 3.8 days.

Trauma and orthopaedics non-elective patients at Gloucestershire Royal Hospital was 7.4 days, which is lower than the England average of 8.7 days.

Ear, nose and throat (ENT) non-elective patients at Gloucestershire Royal Hospital was 1.7 days, which is lower than the England average of 2.2 days.

Non-Elective Average Length of Stay - Gloucestershire Royal Hospital


Cheltenham General Hospital - elective patients From June 2017 to May 2018 the average length of stay for all elective patients at Cheltenham General Hospital was 4.0 days, which is similar to the England average of 3.9 days. For the top three specialties by admission:

Trauma and orthopaedics elective patients at Cheltenham General Hospital was 4.1 days, which is higher than the England average of 3.8 days.

Urology elective patients at Cheltenham General Hospital was 3.2 days, which is higher than the England average of 2.5 days.

Vascular Surgery elective patients at Cheltenham General Hospital was 4.9 days, which is similar to the England average of 5.1 days.

Elective Average Length of Stay - Cheltenham General Hospital



Cheltenham General Hospital - non-elective patients The average length of stay for all non-elective patients at Cheltenham General Hospital was 4.9 days, which is the same as the England average of 4.9 days. For the top three specialties by admission:

General surgery non-elective patients at Cheltenham General Hospital was 4.1 days, which is higher than the England average of 3.8 days.

Urology non-elective patients at Cheltenham General Hospital was 3.7 days, which is higher than the England average of 2.9 days.

Trauma and orthopaedics non-elective patients at Cheltenham General Hospital was 6.5 days, which is lower than the England average of 8.7 days.

Non-Elective Average Length of Stay - Cheltenham General Hospital




The service took account of patients’ individual needs and delivered basic arrangements

for this. However, this could be improved to ensure this was consistently delivered across the

surgical service.

Staff had access to interpreting services for patients whose first language was not English.

Face to face translators could be booked in advance at preoperative assessment clinic and

interpreters could accompany patients to theatre or on ward visits to support care, treatment and

assessments. However, staff on Alstone ward at Cheltenham General Hospital reported some

delays in obtaining translation services stating they had to wait one or two days. In two instances,

staff indicated they used family members to pass on information, which is not recommended best

practice.


There was a range of information leaflets and literature available for patients to read about

a variety of conditions and support services available. When asked staff were not sure of the

process to obtain these leaflets in a different language.

The surgical wards did not have easy read signage to aid people living with dementia or a

learning disability. However, staff did have access to aids, such as picture boards, to assist with

communication.

The trust used a purple butterfly scheme to identify patients with additional needs such as

those living with a diagnosis of dementia or learning disabilities. We saw this in use across

both hospital sites.

The surgical division was well supported by the learning disability team when patients

living with a learning disability were on surgical wards or undergoing surgery.

Arrangements were made to help support these individuals.

Meeting the needs of patients living with dementia across the trust was variable.

Environments were not adapted to make them more dementia friendly. Patients with

dementia or learning disabilities were prioritised to the beginning of lists if possible to help

minimise any distress. The trust used the ‘This Is Me’ tool to support these patients. This tool

provided staff with personalised information about their needs to include how to recognise when

they were becoming distressed and how to reduce this. Wards had access to fiddle muffs for

dementia patients to help reduce their anxiety. Both Prescott ward at Cheltenham General

Hospital and ward 3A at Gloucestershire Royal Hospital talked about their access to these for their

patients.

Staff reported that visiting hours were extended so that relatives and carers could stay with

patients living with dementia, and if there were no relatives or carers, a healthcare assistant

would be assigned on a one to one basis to support patients. Staff tried to place patients

living with dementia in a bed within clear sight of a nursing station.

Access and flow

Patients were not always able to access the service when they needed it. Waiting times from

referral to treatment was delayed and not in line with good practice for some specialties.

In July 2018 there was 115 patients waiting more than 52 weeks. The highest number of breaches

included; 30 breaches in general surgery, 20 breaches in colorectal surgery and15 breaches in

trauma and orthopaedics. In September 2018 there were 106 breaches. The highest number of

breaches included; 34 breaches in general surgery, 17 breaches in upper gastrointestinal

surgery,10 breaches in colorectal surgery and 10 breaches in trauma and orthopaedics. All

patients were reviewed on a weekly basis.

Patients did not always have access to care and treatment in a timely way. We reviewed the

trust’s own data for referral to treatment time performance for 18 week waits. Overall the actual

performance in May 2018 across all specialties was 71.3%. This was projected to improve each

month. Although this is not validated NHS England data, when compared to the national England

average of 67% in May 2018, the trust was performing slightly better.

Performance of urology and general surgery was below the England average. Specialties

performance, comparing trust unvalidated data for May 2018 compared to NHS England average

is in the table below:

Specialty grouping Trust Result (unvalidated) England average (NHS England validated)


General surgery 35.7% 72.8% Urology 57.2% 76.9% Trauma & orthopaedics 62.9% 60.8% ENT 63.3% 63.4% Oral surgery 71.7% 61.3% Ophthalmology 73.4% 70.0%

Performance was also reported by the trust for the following specialties:

Specialty grouping Trust Result (unvalidated) Breast surgery 92.3% Vascular surgery 82.4% Colorectal surgery 73.9% Upper GI surgery 68.5%

The trust was unable to deliver reporting on national waiting time standards. Data quality

issues following migration to a new electronic patient records system meant the trust needed to

suspend national reporting of the referral to treatment position (percentage within 18 weeks) and

patients who had been waiting for over 52 weeks. This had been suspended since November

2016. The trust told us they continued to monitor and address the data quality issues and manage

long waiting patients on the referral to treatment pathways. They reported to board how they will

continue to see 52-week breaches until the full data cleansing exercise was complete.

Systems used by the trust did not help to promote flow and efficiency in theatres and

risked the safety of patients. During our inspection we saw numerous work arounds and gaps in

processes. However, these were well known to the trust and being reviewed and improved and

were included on the divisional risk register.

The flow through both hospitals was now being monitored, evaluated and prioritised with a

focus on patient safety. However, the system was challenged due to the number of patients who

required admission exceeding available beds, and the delays in discharging medically fit patients.

Capacity review meetings were held throughout each day to review flow, admissions,

discharge planning and escalation. Meetings were attended by representatives from surgery.

The site manager was observed attending wards at both hospital sites to review potential

discharges. The site team worked across both hospital sites.

A winter pressure plan had been developed but was only in draft form at the time of our

inspection in early October. This was late in the year for the plan not to be available to staff. It

was due to be presented to the executive board shortly after our inspection. This provided

guidance for staff on the plan to follow during periods of increased admissions and to ensure flow

was managed.

At Cheltenham General Hospital the day case units were open to escalation, and additional

staffing resourced to ensure the unit could stay open and admit medical patients. The sister

told us site managers were good at discussing the correct patients, for example those who were

low risk or likely to be discharged.

Surgical wards planned discharge on admission and continued discharged planning, as

per the trust’s discharge policy. An expected date of discharge was agreed within 12 hours of

admission. The discharge team helped to support wards to discharge patients and follow up in the

community any delays. We observed the discharge team visiting wards to review patients who

were medically fit and help co-ordinate discharges.


In Gloucestershire Royal Hospital there was a discharge waiting area open 8am to 8pm

seven days a week, this was used while patients waited for transport or medicines. Patients

who were medically fit were moved to gallery ward while waiting for ongoing packages of care.

At Cheltenham General hospital there was no discharge waiting area, however some wards had

day room facilities where patients could wait for medicines and transport.

Delays to discharge were sometimes attributed to difficulties finding placements for people living

with mental health needs and learning disabilities.

There were delays with patients being discharged from recovery due to a lack of beds in

the hospital. An audit was completed to look at patients who had an extended stay in recovery

requiring addition nursing input (high dependency care). The reason for staying in recovery was

documented, for example no high dependency unit beds or lack of high dependency staff. We

were told approximately three or four audits were completed a day at Gloucestershire Royal

Hospital for patients waiting in recovery despite being ready for discharge.

There was a 24-hour emergency theatre at Gloucestershire Royal Hospital and an 18-hour

emergency theatre at Cheltenham General Hospital. The Royal College guidance was used

when prioritising and operating on urgent patients, this was reviewed continually. There was an

emergency co-ordinator to support this process.

There was an improved oversight for theatres and theatre utilisation, and this was being

reviewed as part of the theatre transformation project. Theatre transformation work was

looking at how the trust could create effective and efficient booking and maximise theatre

utilisation. We reviewed and discussed the theatre improvement plan. Areas of focus included

electronic pre-op recording, planning and scheduling, staggered admissions, start times and

turnaround times, review of theatre electronic reporting, new clinical model, and community

hospitals. Since October 2017 theatres had been arranged to complete all day lists with single

theatre use. The theatre utilisation policy was in draft form as was in the process of being updated

to reflect all the changes across the surgical service.

It had been identified turnaround times in theatre were higher than the national average.

Therefore, a transfer team was put in place and trialled, which saw a reduction in turnaround

times. This was going to be trialled across further theatres.

At the time of our inspection there were multiple methods of adding patients to operation

lists and booking sat with individual specialties. This was being reviewed as part of the theatre

transformation project to implement centralised booking to streamline the system from outpatients,

pre-assessment and operation lists. Booking rules had been reviewed with surgeons. Theatres

were trying to get two weeks’ notice in advance of lists and identify one golden patient per list. The

golden patient would be the first patient on the list which would not be changed, this was

introduced approximately eight weeks before our inspection. At two weeks theatre lists were

locked down and only changed by management.

Schedulers reviewed specialties and scheduled urgent, cancer and patients breaching

referral to treatment times as a matter of priority. The general manager identified any patients

breaching over 45 weeks to try and book these patients in. Any cancelled patients were reviewed

by the staff booking patients on lists, with an aim of rebooking within 28 days of cancellation.

The trust compared their theatre session utilisation with model hospital and were performing

better, on average at 81%, however they aimed for 90% utilisation.

The trust had seen improvements with their theatre start times. Theatres lists started at 9am each

day.


The trust has been unable to report cancelled operations data to NHS England since November 2016. The trust has commented that this is because of data quality issues following the introduction of a new electronic patient record system.

The trust did not need to cancel elective patients at the start of the year in 2018 where

operational pressures were high nationally and there was a national directive to cancel

elective patients. The trust was able to continue to treat their elective patients.

There had been challenges in recording the reasons for cancellations as the electronic system

used only had three options. At present this was being manually recorded for reasons for

cancellation. The electronic system has now been changed so there are 12 options for reasons for

cancellation. This would enable easier monitoring and audit of cancellations. Reviewing manual

records between April 2017 and March 2018 the main reasons for cancellations included; patient

did not attend, operation no longer required, patient unfit for surgery, no beds, list overrun or

cancelled for an emergency.

We asked for data to show how the trust were monitoring patients with cancer whose

operations were cancelled and to evidence they were rebooked within 28 days. This data

was not provided to us and therefore we cannot be assured this was currently being monitored.

The availability of porters sometimes impacted on the flow within the surgical service at

Gloucestershire Royal Hospital. The porters were part of an external contracted service. Some

staff reported problems with the number of porters and accessibility. We saw an example of this

when visiting Ward 2A (trauma and orthopaedic ward) one patient arrived on the ward but their

bed space was not ready. The patient was therefore waiting for approximately 20 minutes in the

ward corridor before being taken to the bay. This did not allow for the privacy and dignity of the

patient. The bed space was not ready because the patient in the space needed to go to theatre,

but there were not porters available. The sister and a healthcare assistant therefore had to take

the patient to theatre, this momentarily impacted on the staffing on the ward. We also saw several

beds in corridors outside wards in tower block, waiting to be collected by porters.

During our inspection when visiting the day surgery unit at Gloucestershire Royal Hospital one

patient was cancelled and sent home as the equipment required for their surgery was not

available.

The pre-operative assessment clinic reported a backlog of patients to be assessed, which

was a risk in terms of replacing last minute surgery cancellations with patients that had

been properly assessed. Senior staff reported the backlog was due to staffing issues and long-

term staff sickness. The risk was being mitigated by holding Saturday assessment clinics in order

to return to a business as normal position and the recent recruitment of new staff. The Saturday

assessment clinics had been taking place in the previous six weeks prior to our inspection. It had

also been agreed by anaesthetists that the pre-assessment validity (how long the assessment

would be valid for prior to surgery) would be extended from 18 weeks to six months so long as

there were no changes to the patient’s condition.


The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff. However, the surgical division took longer than their trust target to investigate and close complaints.


Patients, we spoke with, stated they would know how to make a complaint against the service if they wished. Staff spoken with were informed of learning from complaints. We saw some examples of lessons learnt and changes made on the back of receiving and investigating complaints. Summary of complaints From April 2017 to March 2018 there were 306 complaints about Surgical Care. The trust took an average of 42 days to investigate and close complaints. This is not in line with their complaints policy, which states complaints should be closed within 35 working days. The four most common subjects of complaint in the trust were: Complaint Detail Count of Complaints


Appointments 45

Communications 41


The breakdown by site is shown in the table below. Cheltenham General Hospital From April 2017 to March 2018 there were 105 complaints about Surgical Care at Cheltenham General hospital. The site took an average of 47 days to investigate and close complaints. This is not in line with their complaints policy, which states complaints should be closed within 35 working days. Complaint Detail Count of Complaints


Appointments 17

Communications 15




Waiting Times 5


Prescribing 2

Other 1


management

1


Gloucestershire Royal Hospital From April 2017 to March 2018 there were 194 complaints about Surgical Care at Gloucestershire Royal hospital. The site took an average of 40 days to investigate and close complaints. This is not in line with their complaints policy, which states complaints should be closed within 35 working days. Complaint Detail Count of Complaints



Appointments 27

Communications 26



Waiting Times 7




management

4

Other 2

Facilities 2


Consent 1

Staff numbers 1

End of life care 1

Remaining sites Complaint Detail Count of Complaints



Appointments 1

Consent 1

(Source: Routine Provider Information Request (RPIR) – Complaints tab) Number of compliments made to the trust From April 2017 to March 2018 there were 1,226 compliments within surgery.

The breakdown by site is shown below. Gloucestershire Royal hospital – 307 compliments Cheltenham General hospital – 919 compliments

(Source: Routine Provider Information Request (RPIR) – Compliments tab)


Leadership

There was a new leadership team in many areas of the surgical division, and trust wide, to

strengthen surgical leadership, but time was required for embedding change and actively

shaping culture. The leadership team were knowledgeable about quality issues and priorities

and understood what their challenges were, and the actions needed to address these.


The surgical leadership team included a surgical triumvirate; chief nurse for surgery, chief

of service for surgery, and director of operations for surgery. Triumvirates were then present

for each specialty; specialty director (consultant), matron (nursing) and general manager.

The board has undergone significant change since the appointment of a new chief

executive in June 2016, with only the medial director remaining in post from before this

time. During the CQC inspection of 2017 many senior staff spoke of a previous culture of bullying

and a lack of openness throughout the executive teams. The new senior team and chief executive

spoke of their objectives of improving the culture and working environment for middle to senior and

executive staff. In general staff reported that the leadership team were now more visible. Several

staff across different roles spoke about improved engagement with the executive team and on the

whole they felt they were better listened to.

Staff spoke positively about their local leaders, for example ward managers and sisters,

and surgical matrons.

There was some upset amongst staff with the level of communication received as part of

reconfigurations. For example, nursing movement of wards at Cheltenham General Hospital, and

clinician concerns with movement of specialties. Some clinicians felt they were not adequately

involved in decisions and there had been a lack of transparency. Comments included about being

devalued at the Cheltenham site, and leaders, managers and directors were regularly based at the

Gloucestershire site.

The visibility of leaders was variable across the two sites, and this was dependent on

where individual leadership roles were pulled. For example, the theatre matron was said to

rarely visit Cheltenham General Hospital theatres, although was accessible by phone. The surgical

leadership triumvirate spoke of an intent to attend both sites and do more walk arounds to ensure

their visibility.

Vision and strategy

The surgical division had a vision for what it wanted to achieve and workable plans to turn

it into action. It was not always clear how this was developed involving staff, patients and key

groups representing the local community.

The main strategy for the surgical division was around the service planning, to reconfigure

services to enable a hot (urgent and emergency) and cold (planned) site.

Each service line had developed a strategy to develop services as part of the trust’s

‘journey to outstanding’. This included their objectives to develop the service considering what

outstanding would look like for both patients and staff.

A new business case was being considered to include bringing the liaison services in house and

together, to include; mental health, dementia, delirium and learning disabilities.

Culture

Overall, there was an optimistic culture within the surgical division. Staff spoke positively

about their colleagues and the team work across the hospital. Everyone was focussed on

providing high quality care for patients. There was some palpable excitement in the organisation

around change and staff were engaged with the trust’s ‘journey to outstanding’. However, we did

recognise some divide was seen between the two sites.


A positive culture was promoted amongst staff. The trust had introduced learning from excellence,

using their incident reporting system to capture and celebrate good practice.

Governance

There was a clear divisional risk management and governance structure for the surgical

division. Each specialty held clinical governance groups. A surgical divisional board was held

monthly and escalated to the trust level committees and to board. The surgical division triumvirate

(tri) held weekly meetings. Each service line held quarterly reviews within their own tri.

Other meetings which formed part of the governance structure and reported to the surgical

divisional board included:

Monthly surgical modern matron meeting

Monthly surgical governance pressure ulcer group

Monthly surgical quality and assurance mortality group

Monthly health and safety

Monthly general managers meeting

Fortnightly surgical cost improvement plan

Weekly check and challenge

Monthly theatre scheduling

Monthly theatres collaborative group

Weekly theatres transformation group

Weekly resource panel

Monthly staff engagement group

Six weekly tri to service line tri

We reviewed meeting minutes for surgical specialties and theatres. These showed risks, incidents,

mortality and morbidity, alerts, and clinical outcomes, were regularly discussed, and learning

points identified.

The Surgical Quality Assurance and Mortality Group (SQAG) oversaw specialty governance

arrangements. Each specialty attended annually to present. This group reviewed governance

processes, clinical outcome data and national audits. It also reviewed new interventional

procedures based on safety and governance rather than finance, serious incidents, and themes

from duty of candour incidents. The SQAG reviewed governance processes for each specialty and

RAG (red, amber, green) rated and benchmarked the specialties to see if they could provide the

correct information, for example meeting minutes, up to date data, individual surgeon data, and

action plans.

Each specialty governance group was responsible for their own reviews of mortality and

morbidity within their clinical governance structures. A hospital mortality group meeting was

also held monthly and attended by the surgery chief of service and the surgery divisional risk

manager. Consultants also attended when available.

Each specialty had a quality assurance and quality assurance audit plan, and this was reviewed

by the surgical quality and assurance mortality group.


Additional meetings held included sister’s meetings which were held every couple of

months, with an agenda which followed the Care Quality Commission prompts. Wards and

theatres held team meetings, when capacity allowed, to ensure important messages could be

shared.


The risks in the service were understood by staff and leaders, and there was a clear

process for escalation of risks. However, known risks were not always clearly demonstrated

within risk registers or mitigated effectively.

There was a divisional risk team who had oversight of the risk register, incidents, audit,

compliance with health and safety, mortality and morbidity, and clinical outcomes. A

monthly presentation was completed to the divisional board to inform of serious incidents, learning

from moderate harm incidents, safety alerts, dashboard triggers, learning from serious complaints,

new risks and risks requiring escalation.

Surgical specialty risk registers were held, and the responsibility lay with the specialty

clinical governance group. Risks above eight were escalated to the surgical division risk

register, monitored by the specialty clinical governance group with oversight by the divisional

board. Risks of 12 plus for safety, 15 plus for other domains and catastrophic ratings triggered

escalation to the corporate risk register.

There were no review dates for risk registers, or a clear trail of dates of added and reviewed

risks. We reviewed the surgical division risk register and specialty risk register for trauma and

orthopaedics and theatres.

The management of risks could be improved, control measures did not always clearly show

what was being done to keep patients safe. One risk for theatres was ‘the risk of complete

power failure during intrusive surgery due to no uninterrupted power supply, leading to potential

loss of life to patients (theatres 5, 4, 3, Apollo, phoenix, eye theatres 1 & 2)’, for this risk there

were no control measures in place, and it stated, ‘none possible’. Therefore, there was no

consideration of what would happen in this instance to keep patients safe. Another example of a

risk was ‘the risk to quality of care of patients remaining in recovery when they no longer require

high dependency care’. The control measures were ‘breaches of policy escalated to bed

management’. However, there was no record of how these patients would be managed in these

instances.

There was no evidence on the risk registers of a risk around the never events which had

been occurring in the division. Although this was a known risk to service leaders.


The information used in reporting, performance management and delivering quality care

was not always accurate, valid and reliable. Problems with the electronic booking system had

hindered the trust’s ability to report referral to treatment times, and to analyse theatre

performance. However, work arounds were being completed and information was being reviewed.

Surgical dashboards were held to review performance. We were told these would be reviewed

to ensure data was presented clearly and the dashboards could be used proactively.

Engagement


There was a basic level of engagement with staff and the public. Although the quality

improvement projects were key in proactively engaging and involving staff and patients in shaping

and improving the service.

The staff survey for 2017 was reviewed and used to develop specialty actions and

improvements. For example, division wide there was a commitment to do walkabouts to all areas

within the division monthly, with a focus on anaesthetics due to the low negative scoring. In head

and neck/ophthalmology there were plans for more staff engagement meetings. In urology/breast

there were plans to promote ‘see something/say something’ due to high levels of none reporting.

The friends and family test and patient feedback was relied on as a form of patient engagement.

Some wards had introduced a 'Freda the Feedback Frog', which allowed patients and visitors to

write real time feedback.

A web-based platform was used to share information for staff about theatres. This included

important messages and information on performance.


The surgical division promoted learning, continuous improvement and innovation. Staff

were passionate about quality improvement projects and quality improvement appeared well

embedded. Staff were provided with quality improvement bronze training and understanding, and

then would move to quality improvement silver projects. During 2018, 164 members of the surgical

division completed their bronze quality improvement training. There were ten members of the

surgical division who had completed their silver quality improvement training and improvement

projects related to safety, experience and effectiveness. There were 27 improvement projects

being undertaken in the surgical division.

Examples of projects included:

Theatre cap challenge. Theatre caps had been ordered which were colour coded for role

and had each person's name embroidered. This aimed to help with communication and

teamwork in theatres.

Day surgery at Gloucestershire Royal Hospital walking in a patient's shoes, using patient

experience to improve services. Staff shadowed patients from meeting them in the hospital

entrance to their day in the day surgery unit.

Day surgery at Cheltenham General Hospital introducing a clear alert of any additional

patient needs to be communication throughout the patient pathway.

Implementing nutrition assistant in trauma and orthopaedics to support patients with their

nutrition and improve patient outcomes.

There was a keenness to learn from other healthcare providers and stakeholders to help

develop surgical services. We heard numerous examples of how communication with providers

and visits to observe practice have helped learning and development of surgical services.

Getting It Right First Time (GIRFT) was being used across the surgical division. GIRFT is a

national clinical programme, working with frontline clinicians to identify and reduce unwarranted

variations in service delivery and clinical practice. For example, GIRFT had been used for the

transformational change for the trauma and orthopaedic team

Surgical wards were being measured for their quality of nursing care. The trust was

participating in a nationally recognised nursing assessment and accreditation scheme. This is

designed to measure the quality of nursing care delivered by individuals and teams, and support


nurses in practice to understand how they deliver care, identify what works well and where further

improvements are needed.

The NHS improvements collaborative for enhanced care work, to enable learning from

excellence, was being explored on wards 2A and 3A at Gloucestershire Royal Hospital. The

surgical division led the programme to develop innovative ways to improve care and safety for

patients requiring enhanced care. The trust told us as a result the wards participating in the

programme had fewer complaints, fewer patients falling and fewer pressure ulcers. The work

developed by the surgical division was not being implemented across the organisation.

Outpatients

Facts and data about this service Gloucestershire Hospital NHS Foundation Trust provides outpatient services for a population of approximately 600,000. The outpatient services are predominantly provided in departments in Gloucestershire Royal Hospital and Cheltenham General Hospital and several community hospitals. The general outpatient departments at both hospitals are managed by the same team of senior staff and staff work between the two sites. Some of the outpatient departments are managed by their own specialties and these include; orthopaedics, ENT, ophthalmology, women and children, amputee rehabilitation unit and oncology (Source: Acute Provider Information Request (PIR) – Acute context tab)


Total number of first and follow up appointments compared to England The trust had 697,115 first and follow up outpatient appointments from June 2017 to May 2018. The graph below represents how this compares to other trusts.

(Source: Hospital Episode Statistics - HES Outpatients) Number of appointments by site The following table shows the number of outpatient appointments by site, a total for the trust and the total for England, from June 2017 to May 2018.

Site Name Number of spells Gloucestershire Royal Hospital 359,551 Cheltenham General Hospital 279,368 Gloucestershire Hospitals NHS Foundation Trust

30,279

Cirencester Hospital 17,203 Stroud General Hospital 17,199 This Trust 754,892 England 106,785,632 (Source: Hospital Episode Statistics) Type of appointments The chart below shows the percentage breakdown of the type of outpatient appointments from


June 2017 to May 2018. The percentage of these appointments by type can be found in the chart below: Number of appointments at Gloucestershire Hospitals NHS Foundation Trust from June 2017 to May 2018 by site and type of appointment.

(Source: Hospital Episode Statistics) During the inspection visit, the inspection team:

Spoke with 15 patients and four relatives. Visited clinics and departments including ophthalmology, urology, fracture clinic, pain

management, phlebotomy, weight control, oncology, gynaecology, cardiology, elderly medicine, dermatology, breast care, blood test clinic, audiology, physiotherapy and dietetics.

Reviewed 10 sets of patient records. Appraised performance information from and about the Trust, including policies,

procedures and audits. Spoke with 64 members of staff including doctors, managers, nurses, physiotherapists,

dieticians, podiatrists, health care assistants and administrative staff. Met a range of service managers responsible for leading and managing services.


Mandatory training

The service provided mandatory training in key skills to all staff and made sure everyone completed it. The trust did not produce specific overall outpatient department figures for mandatory training. Completion rates for training were recorded within the individual divisions or specialities in medicine or surgery. The trust set a target of 90% for mandatory training and the completion rates for surgery and medicine were all around this figure. For example, a breakdown of compliance for mandatory training courses as of June 2018 for qualified nursing staff in medicine at Gloucestershire Royal Hospital is shown below:


trained Eligible

staff Completion

rate Trust

Target Met

(Yes/No)











Manual Handling - People 185 219 84% 90% No At Gloucestershire Royal Hospital the 90% target was met for five of the 10 mandatory training modules for which qualified nursing staff in medicine were eligible. However, all the nursing staff we spoke with working in the outpatient areas on both sites were up to date with their training. We saw the training records for 10 staff that showed training had been completed. Managers explained how they monitored training and provided reminders when this was needed. Staff we spoke with, including therapists, health care assistants and reception staff were positive about the process for supporting them to keep their training up to date. We also saw that reminders about training were displayed on posters in staffing areas. We were told by some staff they would be given some designated time to complete training if needed due to work pressures.

Safeguarding

Staff understood how to protect patients from abuse. There were clear processes for reporting safeguarding concerns and support was available to staff. Staff received training to recognise the signs and symptoms of potential abuse. Staff we spoke with across the different specialities were aware of the trust safeguarding team and the process to follow to access support or advice and guidance. Staff we spoke with understood their responsibilities to raise concerns regarding the welfare of adults including vulnerable adults who used their services. Information regarding safeguarding was displayed in various staff areas. Senior staff we spoke with could all identify the trust safeguarding team, including the named nurse for safeguarding, and were aware of how to contact them when required. We spoke with reception staff who gave an example of how a flag on their booking system informed them to contact social services if the patient attended an appointment. They escalated the concern to the consultant and the call was made. In the optometry clinic staff also explained the process they followed if a child did not attend for two appointments. A safeguarding letter would be sent to the GP and a referral to the safeguarding team could be made. The trust provided the appropriate level of training for individual staff depending on their role and responsibilities. This was in line with national guidance. Staff within the gynaecology department were aware of and knew how to identify risks associated with female genital mutation (FGM) and sex exploitation.

Safeguarding training completion rates The trust did not provide a breakdown of safeguarding training completion for the staff working in the outpatient departments but a target for compliance was set for all staff of 90%. Completion rates for training for recorded within the individual divisions or specialities in medicine or surgery. The senior staff we spoke working in the outpatient’s department had all completed safeguarding training to the appropriate level.


The service-controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection. There were systems and processes in place to protect patients and visitors from the risk of infection.


The outpatient areas visited by the inspection team on both Gloucestershire Royal Hospital and the Cheltenham General Hospital were found to be visibly clean and tidy. The exception to this was the dermatology clinic on the medical outpatient’s wing in Gloucester. This area was not as visibly clean as other areas. The matron in charge of the clinic was aware of the issues and had escalated the concern through to their manager. We looked at the patient waiting areas in both sites, the clinic rooms, treatment areas in the therapies departments and the toilets. We found all were clean and hygienic. We found that store rooms and stock rooms were also generally clean and tidy. Regular infection control audits were undertaken, and the results provided the outpatient matrons and the individual clinics. The sample we looked at were all compliant. There were also cleaning schedules in place for the cleaning to be done by the nursing staff or healthcare assistants. For example, in the surgery outpatient area each staff member had a designated room they were responsible for cleaning, which included completing a deep clean on a regular basis. This was done in addition to the daily cleaning completed by the contracted cleaners. Clinicians we spoke to working in the surgery outpatients, told us the area was always “spotless” and that the staff were “fastidiously diligent about the cleanliness and hygiene” standards. On both sites urgent requests for additional cleaning or for dealing with spillages were responded to promptly by the cleaning staff. Nursing staff in charge of clinics told us that the standards were maintained and that any concerns about the quality of cleaning were reported and acted upon. Staff generally adhered to the trust policy for preventing health-associated infections. All staff we observed were bare below the elbow, in accordance with trust policy. Handwashing facilities and hand cleansing gels were available throughout all the outpatient areas visited by the inspection team. All staff performed hand cleansing before and after patient contact or clinical procedures. We observed staff regularly using the handwashing gel dispensers that were located around the hospital when moving from one clinic area to another. Personal protective equipment (PPE) such as aprons and gloves were available throughout clinical areas. We observed staff wearing PPE appropriately when handling dressings or conducting clinical examination. Equipment was cleaned after use and labelled appropriately. Clinical waste was managed appropriately to protect patients and staff. There were systems in place for managing hazardous waste in accordance with national guidance. When disposing of single use items, staff segregated clinical waste from general waste denoted by different coloured bin liners. When using sharps, staff ensured a dedicated sharps bin was within reach. Sharps bins were correctly labelled and assembled. We saw that audits were completed in clinics in respect of hand hygiene, hand gel dispensers and the wearing of the appropriate protective clothing.


The service had suitable premises and equipment and looked after them well. However, there was a disparity in the quality of the environments across both sites. In Gloucester there was relatively new and spacious purpose-built outpatient’s area, whereas in the Cheltenham General hospital the age and nature of the building presented some limitations to clinicians running clinics. The lack of space for some clinics placed a challenge on staff to make best use of what was available and ensure areas were clean and equipment maintained. The chemotherapy recovery room in Cheltenham General Hospital was cramped and staff had to be careful they did not trip over equipment.


The eye clinic in Gloucester had a high demand and the lack of space meant there could be issues of patient confidentiality. This was due to there being at times more than one patient in a room at a time. Although there were separate accesses, patients could walk past another patient. Staff explained how they worked the best they good with the environment they had. In the Cheltenham oncology centre, the chemotherapy day room was cramped, and nursing staff were at risk of tripping over equipment. There was a risk that if a patient collapsed there would not be enough room to treat them. We looked a sample of equipment in various clinics across both sites. We saw equipment was tested and recorded and that maintenance had been completed when required. For example, portable appliance testing was up to date. The audiology department had recently replaced a large amount of equipment following capital investment form the trust. Resuscitation equipment was readily available in the outpatient areas or located within easy reach.


Staff could identify and respond to a deteriorating patient within the outpatient environment, including medical emergencies. Reception staff, healthcare staff and nursing staff were aware of their responsibility to notice a patient who may be ill or in need of assistance. Staff described the action they would take and gave an example of how they had responded to a patient they had observed as looking unwell. They had helped return the patient to the sub waiting area so that they could be closely observed by nursing staff. Patients receiving any infusion therapy treatments had an assessment using the National Early Warning Score (NEWS) score. The NEWS provides staff with a method to monitor a patient and detect changes in their physical status. Staff were aware of the signs, symptoms and actions to take for suspected sepsis. Staff we spoke with told us they had completed training as part of their mandatory training. The trust had improved their training compliance since the previous inspection in respect of supporting a CPR situation, with 86% compliance recorded in September 2018. Resuscitation equipment was in place and we saw a sample of records that showed that regular checks were completed and recorded. Staff had received training in the use of the equipment and this was recorded. The trust had audited and reviewed the resuscitation equipment available through the hospitals and a number of new lockable trolleys had been provided.

Nurse staffing

Nurse staffing

The trust reported their staffing numbers for outpatients below for March 2018 and May 2018. The outpatient service increased its fill rate by 12% from March 2018 to be 100.7% in May 2018, indicating the outpatients service was marginally over established for nursing staff. A breakdown by site can be found below. March 2018 May 2018

Location

Actual

staff –

WTE in

month

Planned

staff –

WTE

Fill Rate Actual

staff –

WTE

Planned

staff –

WTE

Fill Rate


in

month



(Source: Routine Provider Information Request (RPIR) –Total staffing tab) Vacancy rates As of May 2018, the trust reported a vacancy rate of 6.3% in outpatients; Cheltenham General Hospital outpatients department: -1.5% (over establishment) Gloucestershire Royal Hospital outpatients department: 10.4% The trust did not report an overall target vacancy rate. (Source: Routine Provider Information Request (RPIR) – Vacancy tab) Sickness rates From June 2017 to March 2018, the trust reported a sickness rate of 11.7% in outpatients; Cheltenham General Hospital outpatients department: 19.2% Gloucestershire Royal Hospital outpatients department: 7.4% This is compared to the trust’s overall target sickness rate of 3.5% (Source: Routine Provider Information Request (RPIR) – Sickness tab) Bank and agency staff usage The trust did not provide total shifts including substantive staff, so we are unable to

provide a percentage usage for bank and agency staff. However, the senior matron in

charge of outpatients across both sites told us they filled all vacant shifts from within the team

and then would use bank staff. As a result, they did not need to use agency staff.

(Source: Routine Provider Information Request (RPIR) - Nursing bank agency)

Medical staffing/ Vacancy rates/ Turnover rates/ Sickness rates This information is routinely requested from trusts in advance of an inspection. However, the trust was unable to provide this information. This was due to the structure of the outpatient’s service and medical staffing data being collected through the individual specialities rather than outpatients overall.

Records

Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-


date and available to all staff providing care. The sample of records we looked at contained the information needed to deliver treatment and safe care in a timely and accessible way. The trust had three separate record libraries. Two were located on site and one was off site. The offsite facility was used to store records for patients who had not accessed the service for more than four years. The records team were able to get a set of records from this site within an hour if required urgently. If a set of notes were requested before 3pm they would be delivered that evening. An audit of temporary patient files was completed in May 2018, which showed that of 22404 files requested 541 temporary files were created, which was approximately 4.1%. Of these records 73 were associated with the fracture clinic, where patients attend without an appointment. Records were generally stored securely in locked containers that protected confidentiality. However, in four areas in clinics on the Cheltenham West Block and East Block outpatient area we found patients records that were not secure and could have been accessed by patients or members of the public. Within the optometry clinic in Gloucester we found crates of records on view. The concern had been raised by the manager and new cupboards had been ordered. In the Gloucester clinics, records were stored securely after being prepped in a locked room behind reception accessible only to staff. Notes could be tracked if not available. Some clinicians told us that notes could be elsewhere in the hospital when dealing with patients with co-morbidities or if a patient had an earlier appointment on a different site. Clinicians told that notes were generally always prepared in advance and available in the clinic. Audiology had an electronic records system in place and clinicians were responsible for updating records at the end of each consultation.

Medicines

The service prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time. We looked at the storage facilities for medications in four clinic areas, across both sites. We found medicines were stored securely and fridges in use were being checked regularly. This was being recorded. Drug cupboards were locked, and access controlled by a key system operated by nursing staff. Prescription pads were kept secure through safe storage and access procedures. In some clinics there were advanced practitioners. These clinicians could act as independent prescribers and had increased access to medicines. All nurse prescribers completed an accredited course, which included workplace assessments. Patient Group Directions (PGDs) were used in accordance with the regulations. PGD’s permit the supply or administration of certain medications within a specified clinical context. We saw examples of PGD’s use within the dermatology service and ophthalmology service. Nurses developed PGD’s with a pharmacist and doctor to administer medications as part of ophthalmic procedures. Patients received specific advice about their medications. We saw this was current and written in a clear and informative style. Within several clinics, such as the oncology service, standardised information sheets for each drug were available for patients.

Incidents

Never Events From August 2017 to July 2018, the trust reported no incidents classified as never events


for outpatients. Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event. (Source: Strategic Executive Information System (STEIS)) Breakdown of serious incidents reported to STEIS In accordance with the Serious Incident Framework 2015, the trust reported two serious incidents (SIs) in outpatients which met the reporting criteria set by NHS England from August 2017 to July 2018. These incidents were a slip/trip/fall meeting the SI criteria and a treatment delay meeting the SI criteria. Comprehensive RCAs were completed, and the learning shared through the department. (Source: Strategic Executive Information System (STEIS)) Staff recognised incidents and reported them appropriately. Managers, when required and appropriate, investigated incidents. Staff understood their responsibilities to record safety incidents, concerns and near misses and report them internally. Nursing staff and managers staff told us they were prompt in completing the recording of incidents and gave various examples of what they would report. Staff we spoke told us they did not always get feedback following the reporting of an incident. However, learning from those related directly to patient safety were fed back. Staff in the medical and also the surgery outpatient’s department in Gloucester had a meeting in the morning before the clinics opened. Any safety briefings or learning could be disseminated at these meetings or staff could be directed to information that was displayed in the staff room or the trust intranet. Specialities undertook a more detailed review of incidents as part of risk management and wider learning. The radiotherapy department produced a regular report that looked at all recorded incident and identified improvements and any required action plans.

Safety thermometer

The safety thermometer was not used as a monitoring tool within the outpatient departments.



The physical, mental, and social needs of patients were holistically assessed. The care and

treatment provided was underpinned by the relevant standards, legislation and evidence-based

guidance.

There were processes within the individual outpatient specialities to ensure national guidance was in place, including information from the National Institute of Health and Social Excellence (NICE). For example, in the nurse led clinics in ophthalmology all new guidance was cascaded through staff meetings and clinical supervision. Within oncology services staff described how they kept updated with guidance around treatments and pathways. In the oncology centre in Cheltenham General Hospital the radiographers had access to bladder scanners, which helped ensure the treatment given was appropriate and in line with best practice.


In the dermatology clinics the latest treatments for alopecia areata were being trialled. This was Diphencyprone (DCP), also known as Diphenylcyclopropenone (DPCP). New treatments for psoriasis were also being used. The gynaecology department in Gloucester ran a colposcopy clinic, which was the biggest and busiest in England. Staff meetings were used to update staff of changes in practice. Multidisciplinary meetings where be used to discuss changes in practice because of national guidance or local audits. Nursing staff we spoke with felt that the meetings kept them up to date. Proformas and documentation were used to support patient care and reflected best practice. Within the physiotherapy service the standard assessment included information about all aspects of a patient’s physical needs. Staff had access to trust policies and procedures via the trust intranet. Staff could access online documents and refer to the trust policies to ensure the appropriate care was given.


Patients who were in the departments for any length of time had access to food and drink sufficient to meet their needs. In some clinics, the eye clinic for example, there were hydration stations available for the patient. These were kept topped up by the staff. On both sites there was good access to café facilities close to the outpatient areas.

Nutrition and hydration was considered as part of the patient assessment where appropriate, and we saw this had been recorded on the patient records we saw. Advice about healthy eating as part of well-being was offered by doctors and nurses. Patients could be referred from the initial clinic they were attending to the dietetic service. Here they would receive advice on their nutritional needs.

Patient outcomes

Follow-up to new rate

From June 2017 to May 2018, the follow-up to new rate for Gloucestershire Hospitals NHS Foundation Trust was lower than the England average. The follow-up to new rate for Cheltenham General Hospital was higher than the England

average. The follow-up to new rate for Stroud General Hospital was lower than the England average. The follow-up to new rate for Cirencester Hospital was lower than the England average. The follow-up to new rate for Gloucestershire Royal Hospital was lower than the England

average. Follow-up to new rate, Gloucestershire Hospitals NHS Foundation Trust.



Competent staff

The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service. Staff were encouraged and supported to develop their skills. There were a wide range of nurse led clinics where the staff had developed the skills and competencies required. These included ophthalmology, dermatology and vascular clinics. Within the physiotherapy department training was provided to develop advanced practitioners. The band four physiotherapist also had a wide scope of practice and had bespoke training to support this. They were able to complete assessments, treatment and holistic assessments which reduced duplication of work. Additional training sessions were provided every two weeks and staff also had one hour a week allocated to spend with a supervisor for clinical support. Staff we spoke with had received annual appraisals and said they were well supported by their line managers within the outpatient department. Appraisal rate data was compiled through speciality rather than the outpatient department overall, but within the clinics we visited all the staff were up to date with their appraisal and their mandatory training, We were told that managers supported them in this respect.


There was professional multi-disciplinary working throughout the outpatient’s departments on both sites. Staff of from different professions worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care. Nursing staff in clinics explained how they coordinated with their colleagues when patients needed to be refereed to other professionals. Specialist nurses worked in many clinics, and there were a number of one stop clinics being run. These included physiotherapy, dermatology and ophthalmology. When required staff could request the support of the hospital learning disabilities support staff to help ensure a patient needs were met in clinic in an understanding way.


Seven-day services

Outpatients on both sites were primarily a five-day service. There were some early evening clinics and occasionally some extra clinics had been run on Saturday mornings. There were no plans to extend to seven-day services but the transformation plan for the outpatient’s departments aimed to bring greater flexibility and access for patients through the relocation of some services.

Health promotion

There was information displayed on notice boards in various clinics providing advice to patients on how to manage their health and support improved lifestyles. In the ENT (Ear Nose and Throat) clinic in Gloucester healthcare assistants were encouraged to consider ways that patients could improve their lifestyles. Suggestions were put on a notice board that was reviewed and updated regularly. We observed patients in several clinics being given advice and encouragement to manage their condition through improving their lifestyle. This was done with a positive and supportive approach. For example, advice about giving up smoking and the support that was available. The physiotherapy departments ran groups to promote healthy living. This included targeted individual exercise and advice sessions out in the community.


Patients were supported to make decisions about their care in accordance with legislation regarding consent and the Mental Capacity Act 2015. Staff ensured patients provided verbal consent before any treatment, or written consent in advance of any procedure. In the patients records we looked at we saw that consent had been asked for and documented. Staff we spoke with were aware of consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS). The Mental Capacity Act was incorporated into safeguarding training. Staff had knowledge and understanding of the processes involved in determining whether a patient had capacity and how to gain consent. Staff explained how extra time would be allowed for an appointment if staff were made aware that a patient had learning difficulties and may need longer. We heard staff discussing the treatment and care options available to patients.


Compassionate care

Patients were treated with compassion, kindness, dignity and respect. Staff took the time to interact with people who used the service in a respectful and considerate way. All the patients we spoke were positive about the care and treatment they had received and the approach of the staff. Patients told us they had received compassionate and sensitive treatment.

We observed all staff members communicating with patients by introducing themselves by name and in friendly and respectful manner. We observed this approach across both sites. Patients we spoke with told that staff were friendly and helpful. A patient who was a regular patient at a vascular clinic told us, “they are always friendly, and I like the way they explain everything so well”.


In the Gloucester department we saw patients arrive to find appointments were cancelled or rearranged. This could be due to an error with appointment letters or a misunderstanding by the patient themselves. Staff treated these patients with kindness and respect. We saw staff would do whatever they could to get the patient seen by a clinician if this was possible. Time was taken to explain the problem, apologise for the situation and provide what reassurance they could.

We saw excellent interactions between staff, patients and their relatives. For example, when a relative had become concerned about the length of time the patient had been in the clinic room, a member of staff went and spoke to the consultant and then returned and provided reassurance to the relative.

In the Gloucester phlebotomy clinic, we observed staff making small talk with patients and putting them at ease.

A chaperone policy was in place for patients who required it and staff explained how they followed this, but always respected the privacy and dignity in the clinic room. Patients told us their privacy and dignity were maintained. In some clinic areas it was difficult to maintain confidentiality due to the close proximity of patients. However, we observed voices being lowered to compensate for this as best as they could. We also observed the reception staff protecting patient confidentiality by talking quietly and being overheard.

When bad news or distressing information need to be given to patients or relatives, staff ensured they used private rooms and patients were not disturbed. One nurse explained how they would always ensure the patient and their relatives had enough time to absorb any information and ensure they felt able to leave safely.

Emotional support

Staff provided emotional support to patients to minimise their distress. We observed staff

providing emotional support to patients and relatives during their visit to the department. Any

concerns were promptly identified and responded to in a positive and reassuring way. For

example, reception staff told us there were regular problems with the booked transport for

patients. This was booked in four hourly slots, which could mean that a patient could have a long

wait until the transport arrived. This could be distressing from some elderly patients who would be

anxious about the wait. We saw reception staff providing reassurance and support for patients in

these situations. They reassured patients they would be contacted when the transport arrived and

ensured they knew how to get drinks and refreshments if this was needed. In Gloucester we saw

that the reception staff member went and spoke to an elderly patient who was having to wait over

two hours for their transport.

We overheard staff dealing with patient's concerns via the telephone. Staff were patient and ensured they had been understood and asked the patient to call back if they had any concerns.

Patients and their relatives who were given a life changing diagnosis were offered support and access to further support services. Staff understood the impact of receiving this information. In some services such as oncology immediate support could be provided buy a specialist nurse and in other services patients were given information about external support they could access.


Staff involved patients and those close to them in decisions about their care and treatment.

At the clinics we visited we saw patients having treatments explained and discussed, and the options that were available if this was appropriate. For example, in the eye clinics the procedures were explained in detail along with the recovery path. In the weight loss clinic, the patient was given support and encouragement as they had successfully followed the guidance following their


operation. In the colposcopy clinic we observed patients being given details about their condition and the reasons for the procedure they were to undergo. We saw that staff were reassuring and provided the time for patients to ask questions. Patients were also provided with post procedural information.

In the oncology centre, prior to having a CT scan, patients with prostate cancer were

invited to take part in a group session to discuss side effects and address concerns. The

engineer could also provide a session on the clinic equipment to help take away the “mystery of it”.

This would often provide reassurance to patients. There were also pre-chemotherapy sessions for

patients where aspects of treatment could be discussed, and any questions answered. We

attended part of one of these sessions and patients told us they found it very useful and

reassuring.



The services provided reflected the needs of the local population by offering choice, flexibility and continuity of care. However, the introduction of a new patient appointment booking system, had presented a number of difficulties in the delivery of services. There had been large increases in waiting times and a build-up of delayed clinic letters that needed to be sent out. As a result of these issues the trust had implemented a recovery programme, with the help of outside specialist professional services. Because of the attendant issues around the data quality, and the complexities of the issues, the trust had an agreement that they would not report referral to treatment times externally until sufficient progress had been made on the problems. This reporting is normally done by all trusts, in-line with national guidance. At the time of the inspection the trust told us they were planning to start reporting official data in February 2019. The trust was producing its own shadow data in preparation for this and to monitor the progress that the recovery programme, and other initiative in place, were making.

The trust had produced an outpatient transformation plan. This had been approved by the trust board in June 2018. An essential aspect the plan was to improve the delivery of outpatient’s services across all the surrounding communities that used hospital outpatient services. This could result in the reshaping of the delivery of some services in terms of location and the provision of more one stop clinics. There could also be centralising of some of the management and organisation functions of the outpatient department. The trust had plans to work with other agencies and stakeholders to develop and shape the outpatient services to best meet the needs of the community. The trust planned to meet the needs of patients by providing an “outstanding service”.

Cheltenham General hospital was a regional oncology centre providing care and treatment to Gloucestershire, Hereford and parts of Wales. The services of radiotherapy, chemotherapy and outpatient appointments were provided in the unit, whilst at a satellite centre they provided radiotherapy and chemotherapy. A mobile unit operated around the community hospitals. This was funded by a charity.

The radiotherapy services provided four clinics performing all ranges of treatment. The service had a range of speciality leads and a consultant radiographer. Historically if a patient had a problem it could take up to four hours for a consultant to attend due to other commitments throughout the hospital. However, with the specialist staff, reviews were conducted within 30 minutes. This produced a much-improved service for patients.

On the Cheltenham General Hospital site we found there were challenges to the efficient running of some clinics due to a lack of space. In the Gloucester hospital the outpatient facilities and premises were appropriate for the services delivered. The exception to this was the phlebotomy clinic that was crowded, and at various times we saw that some patients had to stand. There were times when due to lack of space and capacity the clinic would have to close. This was


due to the high number of walk in patients who were referred by their GP. There were plans in place to start a booking service to better manage the flow and better meet the needs of patients. Within the optometry clinic in Gloucester staff told us they were concerned at times that there was insufficient space to have a private conversation with patients

In the Linc haematology clinics staff were concerned about the lack of space. There were eight haematology doctors, a registrar and a staff grade doctor who all ran clinics at various times. Consultants often had to wait for a room to be available, which caused delays to clinics. There was a very small waiting room, where we saw that several patients had to stand as seating was not available. The phlebotomy clinic was run out of small room which could not always accommodate all the patients. At the Gloucester site there were times when the clinic had to close as they could meet the demand of all the walk-in GP referred patients who arrived. Again, a booking service was being planned to help address these problems.

On both sites there was sufficient parking available for patients, with payment being made on exit. Access to the outpatient clinics on both sites was clearly signposted. Information about the clinics running was also clearly displayed.

Did not attend rate From June 2017 to May 2018, the ‘did not attend’ rate for Gloucestershire Hospitals NHS Foundation Trust was lower than the England average. The ‘did not attend’ rate for Cheltenham General Hospital was similar to the England average. The ‘did not attend’ rate for Cirencester Hospital was higher than the England average. The ‘did not attend’ rate for Gloucestershire Royal Hospital was higher than the England

average. The ‘did not attend’ rate for Stroud General Hospital was higher than the England average. The chart below shows the ‘did not attend’ rate over time. The trust had improved the do not attend rates for clinics, with the most recently data showing an attendance of 93% being achieved.


Proportion of patients who did not attend appointment, Gloucestershire Hospitals NHS Foundation Trust.



The service took account of patients’ individual needs and considered different needs and preferences. Reasonable adjustments were made, and staff supported people with additional needs. Staff across outpatients described how they met the needs of patients who were living with dementia. Some staff had completed dementia awareness training and there also alerts on patient files for staff to take not of any additional needs. Although patients would be usually accompanied by a carer or family member, volunteers could be contacted to escort patients for blood tests or to attend an additional appointment.

Translation services were available for patients whose first language was not English. A telephone interpretation service was also available. Interpreters could be booked to support patients throughout a consultation. This needed to be arranged as part of the booking process. Written information could be translated into different languages on request via the patient advice and liaison service.

Reasonable adjustments were made for patients with physical disabilities. In Gloucester the purpose-built outpatient’s area clinics were accessible and mobility aids such as chairs were available for use. Some of the clinics in the Cheltenham General Hospital were not so easy for patients with physical disabilities to access due to the age of the building. Staff explained how they supported patients to use the easiest route to the clinic they were booked into. Staff from several clinics told us that problems with transport sometimes occurred. The arrangement with the contracted services was that a four-hour window was provided for patients, which could sometimes result in patients waiting a long time and at times patients were still waiting after clinics had closed. This meant arrangements had to be coordinated with other department to ensure elderly or frail patients were appropriately overseen and monitored. Staff said that they would complete an incident form on occasions, but with such a long window for collection, long waits were sometimes inevitable. A new resource containing guidance for supporting patients living with dementia had recently been signed off by senior managers and was being introduced shortly. Staff within outpatients worked hard to ensure people with learning disabilities were able to access services. For example, in orthopaedics the team helped create a social story with the learning disability liaison team. A social story is where what is going to happen is shown through


a series of pictures to help people with communication needs. Staff within the orthopaedics team had parts of their bodies plastered to show every step of the process in photographs. Staff communicated well with individuals, their carers and other services to make adjustments to their care. Staff showed understanding and a non-judgmental attitude when caring for or talking about patients with mental health needs, learning disabilities, autism or dementia. In the phlebotomy clinic staff would access the outreach health team if they needed support to meet the needs of a patient with learning disabilities. Also, if a patient presented who was needle phobic they were allowed to go to the front of the queue to minimise distress. Children who attended were given a “goody bag” as a reward for performing a blood test. These were provided by a local charity. The physiotherapy department had a high number of advanced practitioners. This enabled patients to have rapid access to assessment and advice and helped minimise the number of patients who needed referral to a consultant. The advanced practitioners were responsible for triaging patients. There was physiotherapist consultant who trained the advanced physiotherapists. The oncology department had access to two bedrooms which patients who had travelled from a long distance away could use if they needed. Following treatment there was a wide range of support services available to patients. Some were provided by the trust and some were signposted. These included managing dementia, anxiety management, childcare advice, reflexology and patient experience groups. There were also referrals available to psychological support. There was a “chemo” helpline that patients could call if they had any concerns. This was manned by a staff nurse and staff grade doctor.

Access and flow

Patients could not always access services when they needed them. There was not always timely access to treatment. The trust could not be assured that waiting times for treatment and arrangements to admit, treat and discharge patients were in line with good practice. A new Patient Administration System was introduced in December 2016. Part of the system should have supported the management of Referral to Treatment (RTT). However, implementation had caused a problem with data quality. At the time of the inspection the trust was working through a recovery programme. With agreement with commissioners, suspension of RTT reporting was agreed in January 2017. It was agreed there should be a validated accurate list of patients waiting for outpatient services. The recovery programme started in January 2018, when the trust recorded over 300,000 data quality issues across patient pathways and records. At the time of this inspection this was reported as being reduced to 149,000. It had been identified there were still data quality issues that impact on the accuracy of RTT information. These have been estimated as numbering 41,119. A plan was in place to address this issue, which includes the use of an external company. A new patient tracking list was in operation but did not yet provide all the information required in an accurate enough format. The trust was planning to be operational in reporting RTT data in February 2019 and at the time of inspection had produced shadow performance data. Whilst unvalidated it showed that a range of specialities were not meeting the 18-week target for numbers of patients. There was also evidence from reported incidents of patient harm due to not meeting these targets, and in some cases from patients waiting in excess of 52 weeks. During the initial period following the implementation of the patient administration system there were a number of patients having difficulty with the accuracy and timeliness of appointment letters. A significant amount of work had been undertaken to improve and address these issues, some of which was ongoing. However, these issues had not yet been fully resolved. The trust stated that they did not yet have oversight of the admitted and non-admitted “completed” pathways performance. However, the trust was able to demonstrate there was a


strong downward trend towards achieving their targets. Intensive work had been undertaken by the recovery teams and the managers of the specialities, in terms of monitoring progress and ensuring all possible actions were being. In addition, the central booking team had made a significant contribution to the progress, through training around processes and responding dynamically to the challenges that the system presented. The trust planned to start reporting referral to treatment data in February 2019. The appointment booking systems had been challenged by the new electronic booking when it had been introduced. The managers and staff in the offsite call centre had completed a number of initiatives to improve the service they delivered. The centre received an average of 4000 calls per week, with 90% being answered within one minute. There was a weekly “check and challenge” meeting for all specialities across the trust. This weekly meeting looking at the performance of referral to treatment against the planned service delivery. Specialties were required to account for their performance. This also ensured that specialities had up to date oversight of the waiting lists within their areas. The waiting lists were monitored through a “Patient Tracking List”. Information from the weekly meeting were fed into the planned care delivery group. Managers explained how they got feedback from reported incidents from outpatients around appointment and clinic issues. They used the information to drive improvements and improve the processes the team were using to book appointments and clinics. Staff within the call centre had completed work to improve service delivery. Improved end to end process guides for the booking system had been produced, more face to face training had been provided along with improved competency checks and improved supervision for staff operating the new systems. Task lists had been developed that gave staff a clearer idea of the order and structure of tasks. Work was being done to provide more task lists which were less generic and more specific to each speciality they were booking patients into. These had all been issues that had been very challenging to the call centre team when the new system had fist come into operation. All GP referrals had had a “paper switch off” in June 2018 and were now all done electronically. This process had gone smoothly, and we were told that NHS Digital were using the Gloucester process as an exemplar for other services approaching this process. A report on data quality was being completed weekly by the managers. Managers told us they were proud of the commitment and work the call centre had undertaken during a very challenging period. The team had been shortlisted for a staff services award. These were when a team get nominated by another part of the trust. There were also plans to move the call centre onto or near the main site of the Gloucester hospital. A planned benefit of this was better working and understanding between the booking staff and the different specialities. Some specialties told us they were meeting their referral targets. For example, the audiology outpatient service was able to demonstrate they were achieving the target of 18 weeks to treatment. New assessments were all being completed within 8 weeks. All neo natal screening tests were also being completed within the required timescale. The manager explained how the team of audiologists had been proactive in working through the challenges of the IT system. This had helped to minimise the some of the negative effects on patient bookings that the team had to manage. The team had also taken back some responsibility for patient appointment bookings, this was due to the specialised nature of some appointments. Another effect of the problems caused by the new patient booking system had been a build-up of a typing backlog for patient letters following clinic appointments. These backlogs were monitored weekly and reported on in the check and challenge meetings. Some letter writing had been outsourced and staff worked some Saturdays to clear some of the


backlog. Referral to treatment (percentage within 18 weeks) – non-admitted pathways The trust has been unable to report referral to treatment data to NHS England since November

2016. The trust has commented that this is because of data quality issues following the

introduction of a new electronic patient record system in December 2016.

Referral to treatment (percentage within 18 weeks) non-admitted performance – by specialty The trust has been unable to report referral to treatment data to NHS England since November



Referral to treatment (percentage within 18 weeks) – incomplete pathways The trust has been unable to report referral to treatment data to NHS England since November



Referral to treatment (percentage within 18 weeks) incomplete pathways – by specialty The trust has been unable to report referral to treatment data to NHS England since November



Cancer waiting times – Percentage of people seen by a specialist within 2 weeks of an urgent GP referral (All cancers) The trust is performing worse than the 93% operational standard for people being seen within two weeks of an urgent GP referral. The performance over time is shown in the graph below.


Percentage of people seen by a specialist within 2 weeks of an urgent GP referral (All cancers), Gloucestershire Hospitals NHS Foundation Trust

(Source: NHS England – Cancer Waits) Cancer waiting times – Percentage of people waiting less than 31 days from diagnosis to first definitive treatment (All cancers) Percentage of people waiting less than 31 days from diagnosis to first definitive treatment (All cancers), Gloucestershire Hospitals NHS Foundation Trust The trust is performing better than the 96% operational standard for patients waiting less than 31 days before receiving their first treatment following a diagnosis (decision to treat). The performance over time is shown in the graph below.

(Source: NHS England – Cancer Waits) Cancer waiting times – Percentage of people waiting less than 62 days from urgent GP referral to first definitive treatment

The trust is performing worse than the 85% operational standard for patients receiving their first treatment within 62 days of an urgent GP referral. The performance over time is shown in the graph below.


Percentage of people waiting less than 62 days from urgent GP referral to first definitive treatment, Gloucestershire Hospitals NHS Foundation Trust

(Source: NHS England – Cancer Waits)

Clinic areas were utilised effectively to meet the needs of patients. Measures were in place to help ensure that the department made the most efficient use of clinic areas. A designated administrator was responsible for booking clinic rooms and ensuring the correct staff were available to support the clinic. This helped ensure the optimal use of clinic rooms. Some problems had been encountered when part of the electronic booking system did not contain all the clinic rooms to allow allocation to clinic activity. Another problem the staff had to manage was that the electronic appointment booking system did not interface with the electronic room booking system. Medical and nursing staff running clinics told us the clinic booking arrangements were now working well and they appreciated the work the administration team put into getting the department running efficiently in this respect. Patient with the most urgent needs did not always have their care and treatment prioritised. The Thirlstaine Breast Centre in Cheltenham General Hospital offered a one stop clinic for any patients suspected of having breast cancer and having ongoing treatment. Patients could attend and have their screening biopsy and clinic appointments all on the same day. This helped ensure they received their treatment as soon as possible. There was a plethora of signposted services for patients. This helped to support the move away from patients having consultant appointments to a more self-managing care. Patients were given phone numbers and offered remote advice and GP support, before coming back for further appointments. However, access to radiography and diagnostic services due to high demand could cause delays to the meeting of the cancer waiting targets. The orthopaedic and trauma clinic in Gloucester was unable to meet their target of seeing new fracture patients within 48 hours, with some patients waiting 7 days for a follow up appointment. Some patients due follow up appointments within four months were waiting up to six months for an appointment. In order to help address this, there was a virtual clinic and triage completed every morning by the clinicians. This helped ensure improved utilisation of the clinic. We observed that one patient who had been advised not to come back and to see how he progressed contacted the team as they were concerned about their injury. An urgent appointment was booked for the following day. Consultants we spoke with said they believed the triage was working well. They ensured patients were aware of how to contact them directly in triage if they had any concerns. The increased demand in the orthopaedic clinic had been the result of the reconfiguring of services across the two sites. Since this had been started in October 2017 the Gloucester orthopaedic service ran two full patient lists every day. This was an increase in capacity of 30%. There was also a quality improvement plan for one of the ENT (Ear Nose Throat) clinics to implement a virtual clinic for a nasal service in January 2019. This would help minimise unnecessary attendances and save patients from travelling when they did not need to.


Clinics throughout both sites generally started on time and patients were promptly informed of delays. This helped manage anxiety and improve their experience. Throughout both sites we observed that clinics started on time. Information was clearly displayed for patients to see regarding the names of clinics and the clinicians running them. When there were delays this was displayed. We also saw that staff from the clinics would update patients about waiting times. There were signs advising patients if they had not been called after 30 minutes for their appointment, then they should speak to a member of the reception staff. The majority of clinics we observed were running on time, with the longest delays observed being for 30 minutes. In the Gloucester department we spoke with four patients who were regular users of the outpatient service. They said that delays of 10 to 15 minutes were common but was not a problem. They told us they were kept informed and that the reception staff were always very helpful and friendly. An electronic booking system was being effectively introduced in a manner which improved patient experience and also the efficiency of the department. Patients had the option of using an electronic booking in system when they arrived in the department if they chose. Staff explained whilst the system was relatively easy to use, they were also keeping the option for patients to book in at reception. This was reassuring for patients who were unsure of the technology. However, we were told that the electronic booking was being increasingly used as patients became used to it. There were a number of one stop clinics running across both sites. These provided patients with the opportunity to complete a number of activities without making several appointments and visits to the hospital. For example, the ENT (Ear Nose and Throat) clinic had one a one stop clinic for some patients with neck concerns. This clinic meant a patients could be seen scanned, biopsied and given their results at the one visit. We were told that a new dictation system was being introduced for use by some consultants. This would help improve the timeliness of letters being sent to patients. Several consultants had started using the system so far.


Summary of complaints From April 2017 to March 2018 there were 145 complaints about the outpatient’s department. The trust took an average of 37.6 days to investigate and close complaints, this is not in line with their complaints policy, which states complaints should be completed within 35 days. The six most common subjects of complaint in the trust were: Complaint Detail Complaints

Appointments 92

Communications 25




Privacy, Dignity and Wellbeing 2 The breakdown by site is shown in the tables below. Cheltenham General Hospital


From April 2017 to March 2018 there were 36 complaints about Cheltenham General Hospital. The trust took an average of 39.9 days to investigate and close complaints, this is not in line with their complaints policy, which states complaints should be completed within 35 days. Complaint Detail Complaints

Appointments 21

Communications 6




Facilities 1


Trust admin/policies/ procedures including patient record management 1

Waiting Times 1 Gloucestershire Royal Hospital From April 2017 to March 2018 there were 98 complaints about Gloucestershire Royal Hospital. The trust took an average of 37.2 days to investigate and close complaints, this is not in line with their complaints policy, which states complaints should be completed within 35 days.


Appointments 63

Communications 17




Prescribing 1


Trust admin/policies/ procedures including patient record management 1

Waiting Times 1 (Source: Routine Provider Information Request (RPIR) – Complaints tab) Number of compliments made to the trust From April 2017 to March 2017 there were 231 compliments within outpatients split across Cheltenham General Hospital and Gloucestershire Royal Hospital. The breakdown by site is shown in the table below.

Location Compliments Cheltenham General Hospital 84 Gloucestershire Royal Hospital 141 Cheltenham General Hospital/ Gloucestershire Royal Hospital 6

(Source: Routine Provider Information Request (RPIR) – Compliments tab) The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff. Each quarter the Deputy Director


of Quality and Freedom to Speak up Guardian reported to the trust quality and performance committee. They reported the number of reported complaints, the compliance with trust response targets, the number of cases referred to the PHSO (Parliamentary Health Service Ombudsman) and the outcomes of closed cases. Cases referred to the PHSO were monitored by the safety and experience review group, who would also sign off any action plans for partially upheld or upheld cases. During 2017/18 the trust data showed an increase in 24% in complaints made in relation to the booking of appointments. Following the work undertaken to improve the efficiency of the patient booking system, and the work undertaken to support the booking centre staff, it was recorded that these had reduced significantly. There had been a 50% reduction achieved in the most recent quarters figures. There was a designated member of the complaints team who dealt with complaints about the outpatient’s service. The team had undertaken thematic reviews to identify any specific issues. For example, the issue of patients paying for parking for appointments that had been cancelled but had not received letters in respect of. Action was taken to reimburse these patients as the trust had been at fault. The trust board has set an objective of reducing the complaints received about outpatients. This target had been achieved in the previous month to the inspection. At the time when the issues with appointments caused by the new electronic system were most influential there were a considerable increase in complaints. We were told that the peak had been 160 in one month. The most recent figures showed there had been a reduction to 90 in the last quarter. At the time of the inspection the trust had recorded in total a 36% reduction in the number of complaints recorded from the previous year 2017/18 total.


Leadership

The trust had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. Leaders had the experience and skills to ensure that outpatient services improved, risks were identified, and transformation was being progressed. Staff were clear about lines of accountability. All staff had an appropriate level of awareness and involvement in the trust wide plans to address the performance shortfalls caused by the IT implementation. The leadership at all levels had ensured that staff were engaged with the trust “journey to excellence” and the recently approved outpatient transformation plan.

Nursing staff, healthcare staff, managers and reception and administration staff were positive about the support from their line managers. Staff were well informed of ongoing issues and developments. Staff were well informed and positive about the objectives of improving the outpatient service to patients. For example, the teams in the booking centre had received some excellent feedback about their motivation and commitment following a recent training exercise in team building. They had made significant improvements to their service delivery over the previous twelve months. Senior nursing staff and managers told us they had regular contact with their managers. They told us the senior trust staff, including the chief nurse and other board members, had a presence in the department. We were told that they were approachable and interested in their ideas and concerns. Staff we spoke with described improved visibility of leadership at a senior level. One consultant we spoke with told us the accessibility of the senior trust staff was “motivating” and encouraged staff to “think about improvements and then suggest them”.


Vision and strategy

The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff and patients. The trust had produced a “Transformation Plan” for the outpatient’s service they provide. This strategy was signed off by the trust Board in July 2018. The trust had ensured the involvement of stakeholders in taking the strategy forward. There were plans to set up a patient forum, the trust governors were being involved and the commissioners of services had been involved. The strategy is in-line with the trust overall strategy of being on a “journey to outstanding”. The strategy has an objective of providing an outstanding service, with care closer to home and centres of excellence for different specialities. The plan represented a different approach to outpatient services. All staff we spoke with were aware of the plan and positive about the improvements and developments planned. A workshop was planned for the matrons in outpatients with other senior staff including the chief nurse. This would look at developments, staffing, centralisation and leadership. The plan detailed 14 standards of care that the trust aimed to embed across all the outpatient settings. Examples included, making services accessible and timely and undertake all diagnostics and investigations in as few appointments as possible, and to utilise emerging technologies to improve patient care. In order to deliver these standards, the trust had identified objectives and a timeframe. The objectives included, to undertake the “15 steps challenge”, to develop and agree core staff competencies and to ensure they had a sustainable workforce that were supported and trained to provide the right outcomes. Various projects were planned, or underway, to support the delivery of different stages of the patient pathway. These were booking and access, the first appointment, the follow up appointment, and patient aftercare. There was three programme that being proposed from 2018 to 2021.

Individual services also produced reports which identified aims and objectives for improvement. The radiotherapy department produced an annual report that identified objectives for patients, staff the organisation and the service.

Culture

Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff were proud of their work in the outpatient services. They said they felt respected and valued by managers and colleagues. Staff described an open culture where they could raise concerns and suggest ideas. Staff at all levels we spoke with said their managers listened positively.

The trust showed concern for staff wellbeing and safety. Staff told us that the trust supported them in managing any personal matters or health issues. Staff felt managers were supportive and understanding. For example, staff were provided with access to physiotherapy and access to counselling and support services.

Staff worked well with each other and across teams. All staff we spoke with, across both hospital locations, said they enjoyed working with their teams. They felt that teams worked collaboratively and showed appreciation of work done by colleagues.

Governance

There were appropriate levels and structures of governance across outpatient services to ensure safety was monitored and improvements supported. There were clear lines of accountability and reporting. The systems ensured the services functioned effectively. Leaders and managers at all levels of the governance framework were clear about roles. There were clear structures for accountability, from the outpatient’s service managers to the outpatient’s improvement board, which then reported to the planned care board. Within the medical and surgical specialities there were clear reporting structures and lines of accountability. A consultant


we spoke to said they considered there was “now a more cohesive structure of governance for the overall delivery of outpatient services”. There was a weekly check and challenge meeting which all specialities attended. This meeting monitored quality and safety, with particular governance of the performance of the clinics with respect to the IT recovery programme.

There were effective and clear governance structures in place to promote accountability and support the delivery of services. Staff at all levels were clear about their roles and responsibilities. Staff were aware of the responsibility to deliver safe services, and who they were accountable to.

Information was shared through emails, team meetings, and morning meetings. These were used to staff were aware of potential delays and for any concerns to be raised and solutions sought in advance. The meeting could also be used to provide feedback on incidents and complaints. Staff also received information through the individual specialties, which could be newsletters, guidance updates or other staffing information.

Within the therapies division all the service leads reported to the Allied Health Professional director, and all attended regularly at divisional board meetings. The service leads felt the meetings they attended could be described as “high challenge and support culture” that encouraged the exchange of ideas as well as the discussion of concerns and issues.

The matrons team in outpatients had developed a quality metrics record that was completed across the department. This information was fed into the outpatient improvement board, that met monthly, which in turn reported into the planned care board. A performance dashboard for all outpatients and an additional one for the sending out of clinic letters was produced and updated weekly.

However, staff within the radiotherapy team said they sometimes found it difficult to find the time due to work pressure. The speciality director did not always get enough time and with the general manager being split between the services of oncology and diagnostics, there were challenges in always finding sufficient time for governance. However, all staff were trained in the quality management systems which ensured engagement in governance.

A quality assurance checklist had recently been introduced across the outpatient department. The propose was to imbed new practice and ensure consistency. The effectiveness was yet to be audited but some staff would use the checklist at the morning briefing before the clinics started. They would refer to concerns or issues that had been highlighted in the audit. However, It was unclear from some staff how frequently it was being completed and whether it was being used in every clinic. It was a detailed audit covering questions from all the inspection domains.

Senior nursing staff in the orthopaedic and trauma clinic had regular contact with the surgical risk manager and received feedback about any elevated risks or concerns.


There were systems for identifying risks and recording these. Risks were escalated appropriately, and action taken to minimise or mitigate where possible. There was an outpatient risk register and also individual medical and surgical specialities had access to registers within their divisions. Examples of identified risks included equipment in need of replacement and space limitation in some clinics. We saw risks were identified and recorded and this information escalated through the governance process and shared more widely.

The performance of outpatient services was reviewed at a speciality and divisional level through the weekly check and challenge meetings. The overview of performance from these meetings was fed up to the outpatient improvement board and the planned care board, and from there to the trust board. These processes reviewed the current performance and planned for anticipated improvements. This process of audit monitored quality, operational and financial processes.


There were arrangements to ensure the integrity and confidentiality of identifiable data, including records management and electronic information. Computer screens were locked when not in use and records were safely stored. The recovery programme for the IT system had involved ensuring that data quality issues and problems were addressed and thus enabling the trust to work with accurate and current information to monitor performance, address problems and mange improvements. Weekly performance dashboards were produced for outpatients and also a dashboard for the managing of the backlog of appointment letters. The performance measures collected were reported to and discussed at the weekly check and challenge meetings that all specialities attended.

Engagement

The trust engaged well with patients, staff, and the public to plan and manage appropriate services, and collaborated with partner organisations effectively. The outpatient’s department had used the “Sweeny” project to improve their understanding of patient experience. The project involves staff moving through the patient journey from arriving at the hospital through to being seen by a clinician. A major aim is to enable staff to more clearly see the pathway through the “patient eyes”. After one exercise, a result was a change to the some of the signage in one area of the department.

Staff we spoke with were engaged and committed to the trust objective of being on a “journey to outstanding”. For example, in the eye clinic there was a board which displayed staff suggestions for how the service could improve. The matron’s forum had been set up, which involved staff from across both sites and all departments. At these monthly meetings there was standing agenda item on suggested improvements to services and progress that had been made on previous initiatives. There was also a “chance to shine” item where a matron would she one particular issue or action they were proud of from their area of outpatient services.

The outpatient management team had felt they were getting insufficient feedback from the friends and family test, so had started their own initiative in respect of this. In order to improve feedback, they had introduced a new system of patient feedback. Posters were displayed titled “Freda the Frog” and patients were invited to write their comments on cards provided and stick them on the poster. A summary of comments posted was distributed to staff. So far, in the majority of clinics, this was proving to be successful, though some staff were concerned that the poster appeared to be a little childlike.

The radiotherapy department had found that the recording and reporting of feedback as being inconsistent and inconclusive so had undertaken an extensive patient survey, which had covered a wide range of questions. The survey had also produced written feedback from patients. The feedback identified some areas for improvement but was overwhelmingly positive. For example, 100% of patients questioned said they had been treated with as an individual with dignity, kindness and respect.


There was a focus on learning, improvement and innovation throughout outpatient services. Staff were engaged with the outpatient transformation and very positive about delivering an improving and innovative service.

The transformation plan for the outpatient’s service contained a number of imaginative ideas for the improved delivery of service. These included the use of technology for improved remote working and the use of apps. to support patient management. There were plans to provide increased centralisation and standardisation of the reception services across both sites.

Virtual dictation being trialled by a group of ten consultants, this was aimed at improving the efficiency of sending out letters to patients and other professionals.

gloucestershire hospitals nhs foundation trust · assessment or medical treatment for persons...

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