20171116 900885 Post-inspection Evidence appendix template v3 Page 1 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.
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Gloucestershire Hospitals NHS Foundation Trust · Assessment or medical treatment for persons detained under the 1983 Act Diagnostic and screening procedures Maternity and midwifery
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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
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
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.
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
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:
Name of course Staff
trained Eligible
staff Completion
rate Trust
Target Met
(Yes/No)
Equality and Diversity 57 57 100% 90% Yes
Fire Safety 1 Year 56 57 98% 90% Yes
Manual Handling - Object 55 57 96% 90% Yes
Medicine management training 55 57 96% 90% Yes
Information Governance 54 57 95% 90% Yes
Health and Safety (Slips, Trips and Falls) 54 57 95% 90% Yes
Infection Control (Role pathway) 54 57 95% 90% Yes
Adult Basic Life Support 54 57 95% 90% Yes
Conflict Resolution 47 57 82% 90% No
Manual Handling - People 41 57 72% 90% No
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
Name of course 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
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
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
Gloucestershire Royal Hospital
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.
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.
Cheltenham General Hospital
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.
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)
Gloucestershire Royal Hospital
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.
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.
Cheltenham General Hospital
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?
6.7 About the same as other trusts
Q33. In your opinion, how clean was the emergency department?
^ 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.
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
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
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.
Cheltenham General Hospital
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
(Source: NHS Digital - A&E quality indicators)
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
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)
Gloucestershire Royal Hospital
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.
Cheltenham General Hospital
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”.
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.
Gloucestershire Royal Hospital
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.
Cheltenham General Hospital
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?
3.1 About the same as other trusts
Q12. Did you have enough time to discuss your health or medical problem with the doctor or nurse?
8.5 About the same as other trusts
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?
8.9 About the same as other trusts
Q16. Did you have confidence and trust in the doctors and nurses examining and treating you?
8.7 About the same as other trusts
Q17. Did doctors or nurses talk to each other about you as if you weren't there?
9.0 About the same as other trusts
Q18. If your family or someone else close to you wanted to talk to a doctor, did they have enough opportunity to do so?
7.9 About the same as other trusts
Q19. While you were in the emergency department, how much information about your condition or treatment was given to you?
8.7 About the same as
other trusts
Q21. If you needed attention, were you able to get a member of medical or nursing staff to help you?
7.8 About the same as other trusts
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?
9.1 About the same as
other trusts
Q23. Were you involved as much as you wanted to be in decisions about your care and treatment?
8.1 About the same as other trusts
Q44. Overall, did you feel you were treated with respect and dignity while you were in the emergency department?
8.9 About the same as other trusts
Q15. If you had any anxieties or fears about your condition or treatment, did a doctor or nurse discuss them with you?
7.2 About the same as other trusts
Q24. If you were feeling distressed while you were in the emergency department, did a member of staff help to reassure you?
7.1 About the same as
other trusts
Q26. Did a member of staff explain why you needed these test(s) in a way you could understand?
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.
Cheltenham General Hospital
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.
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?
7.1 About the same as other trusts
Q11. Overall, how long did your visit to the emergency department last?
7.8 About the same as other trusts
Q20. Were you given enough privacy when being examined or treated?
9.2 About the same as other trusts
(Source: Emergency Department Survey (October 2016 to March 2017; published October 2017)
Gloucestershire Royal Hospital
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
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
Gloucestershire Royal Hospital
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.
Cheltenham General Hospital
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
Gloucestershire Hospitals NHS Foundation Trust
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.
Gloucestershire Royal Hospital
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.
Cheltenham General Hospital
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
Gloucestershire Hospitals NHS Foundation Trust
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
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.
(Source: Hospital Episode Statistics)
Cheltenham General Hospital
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)
Gloucestershire Royal Hospital
78,438 spells in Gloucestershire Hospitals NHS Foundation Trust
Cheltenham General Hospital and Gloucestershire Royal Hospital
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).
Trust level data – medicine division
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
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
Cheltenham General Hospital and Gloucestershire Royal Hospital
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
Cheltenham General Hospital and Gloucestershire Royal Hospital
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
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:
(Source: Strategic Executive Information System (STEIS))
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
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.
Is the service effective?
Evidence-based care and treatment
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.’
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.
(Source: Hospital Episode Statistics)
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
Cheltenham General Hospital.
At Gloucestershire Royal Hospital we visited the following areas:
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.
Is the service safe?
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:
Name of course Staff
trained Eligible
staff Completion
rate Trust
Target Met
(Yes/No)
Equality and Diversity 688 695 99% 90% Yes
Health and Safety (Slips, Trips and Falls) 661 695 95% 90% Yes
Fire Safety 1 Year 642 695 92% 90% Yes
Medicine management training 642 695 92% 90% Yes
Infection Control (Role pathway) 633 695 91% 90% Yes
Adult Basic Life Support 613 682 90% 90% Yes
Manual Handling - Object 621 695 89% 90% No
Information Governance 604 695 87% 90% No
Manual Handling - People 593 695 85% 90% 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:
Name of course Staff
trained Eligible
staff Completion
rate Trust
Target Met
(Yes/No)
Equality and Diversity 347 375 93% 90% Yes
Health and Safety (Slips, Trips and Falls) 312 375 83% 90% No
Adult Basic Life Support 302 375 81% 90% No
Infection Control (Role pathway) 299 375 80% 90% No
Fire Safety 1 Year 298 375 79% 90% No
Information Governance 298 375 79% 90% No
Manual Handling - People 292 375 78% 90% No
Manual Handling - Object 291 375 78% 90% 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:
Health and Safety (Slips, Trips and Falls) 286 297 96% 90% Yes
Fire Safety 1 Year 280 297 94% 90% Yes
Adult Basic Life Support 277 297 93% 90% Yes
Medicine management training 277 297 93% 90% Yes
Manual Handling - Object 272 297 92% 90% Yes
Infection Control (Role pathway) 272 297 92% 90% Yes
Manual Handling - People 269 297 91% 90% Yes
Information Governance 264 297 89% 90% No
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:
Name of course Staff
trained Eligible
staff Completion
rate Trust
Target Met
(Yes/No)
Adult Basic Life Support 9 13 69% 90% No
Equality and Diversity 8 13 62% 90% No
Manual Handling - People 7 13 54% 90% No
Conflict Resolution 6 13 46% 90% No
Health and Safety (Slips, Trips and Falls) 6 13 46% 90% No
Information Governance 5 13 38% 90% No
Fire Safety 1 Year 5 13 38% 90% No
Infection Control (Role pathway) 5 13 38% 90% 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:
Name of course Staff
trained Eligible
staff Completion
rate Trust
Target Met
(Yes/No)
Equality and Diversity 304 306 99% 90% Yes
Health and Safety (Slips, Trips and Falls) 288 306 94% 90% Yes
Medicine management training 285 306 93% 90% Yes
Infection Control (Role pathway) 284 306 93% 90% Yes
Fire Safety 1 Year 282 306 92% 90% Yes
Manual Handling - Object 274 306 90% 90% Yes
Adult Basic Life Support 257 293 88% 90% No
Information Governance 264 306 86% 90% No
Manual Handling - People 258 306 84% 90% 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:
Name of course Staff
trained Eligible
staff Completion
rate Trust
Target Met
(Yes/No)
Equality and Diversity 12 19 63% 90% No
Adult Basic Life Support 11 19 58% 90% No
Manual Handling - People 10 19 53% 90% No
Fire Safety 1 Year 8 19 42% 90% No
Health and Safety (Slips, Trips and Falls) 7 19 37% 90% No
Information Governance 7 19 37% 90% No
Infection Control (Role pathway) 7 19 37% 90% No
Manual Handling - Object 6 19 32% 90% 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:
Name of course Staff
trained Eligible
staff Completion
rate Trust
Target Met
(Yes/No)
Safeguarding Children (Level 2) 638 695 92% 90% Yes
Safeguarding Adults (Level 2) 597 695 86% 90% No
Safeguarding Adults (Level 1) 594 695 85% 90% No
Safeguarding Children (Level 1) 592 695 85% 90% 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:
Safeguarding Children (Level 2) 310 375 83% 90% No
Safeguarding Adults (Level 2) 264 375 70% 90% No
Safeguarding Adults (Level 1) 264 375 70% 90% 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:
Name of course Staff
trained Eligible
staff Completion
rate Trust
Target Met
(Yes/No)
Safeguarding Children (Level 2) 285 297 96% 90% Yes
Safeguarding Adults (Level 2) 272 297 92% 90% Yes
Safeguarding Adults (Level 1) 253 297 85% 90% 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:
Name of course Staff
trained Eligible
staff Completion
rate Trust
Target Met
(Yes/No)
Safeguarding Children (Level 2) 7 13 54% 90% No
Safeguarding Adults (Level 1) 6 13 46% 90% No
Safeguarding Children (Level 1) 5 13 38% 90% 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:
Name of course Staff
trained Eligible
staff Completion
rate Trust
Target Met
(Yes/No)
Safeguarding Children (Level 2) 278 306 91% 90% Yes
Safeguarding Adults (Level 1) 266 306 87% 90% No
Safeguarding Children (Level 1) 265 306 87% 90% 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:
Safeguarding Adults (Level 2) 4 19 21% 90% No (Source: Routine Provider Information Request (RPIR) – Training tab)
Cleanliness, infection control and hygiene
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
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
^ 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
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 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
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).
(Source: Strategic Executive Information System (STEIS))
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.
Is the service effective?
Evidence-based care and treatment
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.
Nutrition and hydration
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
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
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
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
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
(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
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
NHS infrastructure support 1 1 100%
Qualified Allied Health Professionals
(Qualified AHPs)
29 26 90%
Qualified Healthcare Scientists 10 9 90%
Other Qualified Scientific, Therapeutic &
Technical staff (Other qualified ST&T)
25 22 88%
Support to ST&T staff 12 10 83%
Support to doctors and nursing staff 146 117 80%
Qualified nursing & health visiting staff
(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:
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.
Consent, Mental Capacity Act and Deprivation of Liberty Safeguards
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)
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.
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.
Note: Top three specialties for specific trust based on count of activity.
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
Note: Top three specialties for specific trust based on count of activity.
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
Note: Top three specialties for specific site based on count of activity.
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
Note: Top three specialties for specific site based on count of activity.
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
Note: Top three specialties for specific site based on count of activity.
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
Note: Top three specialties for specific site based on count of activity.
(Source: Hospital Episode Statistics)
Meeting people’s individual needs
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
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.
Learning from complaints and concerns
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
Clinical treatment 110
Appointments 45
Communications 41
Values and Behaviours (Staff) 35
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
Clinical treatment 34
Appointments 17
Communications 15
Values and Behaviours (Staff) 14
Patient Care (Nursing) 7
Admission and discharges 5
Waiting Times 5
Access to treatment or drugs 3
Prescribing 2
Other 1
Trust admin/policies/ procedures including patient record
management
1
Privacy, Dignity and Wellbeing 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
Trust admin/policies/ procedures including patient record
management
4
Other 2
Facilities 2
Privacy, Dignity and Wellbeing 1
Consent 1
Staff numbers 1
End of life care 1
Remaining sites Complaint Detail Count of Complaints
Clinical treatment 3
Values and Behaviours (Staff) 2
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)
Is the service well-led?
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.
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.
Is the service safe?
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:
Name of course Staff
trained Eligible
staff Completion
rate Trust
Target Met
(Yes/No)
Equality and Diversity 214 219 98% 90% Yes
Medicine management training 204 219 93% 90% Yes
Infection Control (Role pathway) 203 219 93% 90% Yes
Health and Safety (Slips, Trips and Falls) 196 219 89% 90% No
Manual Handling - Object 193 219 88% 90% No
Information Governance 191 219 87% 90% No
Conflict Resolution 186 219 85% 90% 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.
Cleanliness, infection control and hygiene
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.
Environment and equipment
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.
Assessing and responding to patient risk
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
Gloucestershire Royal Hospital 12.82 15.17 84.5% 13.4 14.6 92.0%
Cheltenham General Hospital 7.33 7.67 95.6% 7.9 6.6 119.9%
(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.
Is the service effective?
Evidence-based care and treatment
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.
Nutrition and hydration
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.
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.
Multidisciplinary working
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.
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.
Consent, Mental Capacity Act and Deprivation of Liberty Safeguards
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.
Is the service caring?
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.
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.
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.
Is the service responsive?
Service delivery to meet the needs of local people
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.
(Source: Hospital Episode Statistics)
Meeting people’s individual needs
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
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) – incomplete 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) incomplete pathways – by specialty 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.
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.
Learning from complaints and concerns
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
Values and Behaviours (Staff) 10
Clinical treatment 8
Access to treatment or drugs 2
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
Values and Behaviours (Staff) 3
Access to treatment or drugs 1
Clinical treatment 1
Facilities 1
Privacy, Dignity and Wellbeing 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.
Complaint Detail Complaints
Appointments 63
Communications 17
Clinical treatment 7
Values and Behaviours (Staff) 6
Access to treatment or drugs 1
Prescribing 1
Privacy, Dignity and Wellbeing 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.
Is the service well-led?
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”.
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.
Management of risk, issues and performance
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.
Learning, continuous improvement and innovation
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.