Great Western Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We reviewed 7 quality statements in this key question relating to learning culture; safe systems, pathways and transitions; safeguarding; involving people to manage risks; safe environments; safe and effective staffing and infection prevention and control. We found people were protected from the risk of harm and abuse through safeguarding policies and processes. People were supported to understand and manage risk. Care plans were clear, and staff told us they provided sufficient guidance to support people. There were sufficient and appropriately trained staff in place to support people. Safe recruitment processes were followed. However, feedback from staff and leaders regarding patient placement was not always positive and some infection prevention and control practices were observed to be suboptimal. These concerns were raised at the time of the assessment.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The trust had clear processes for disclosing incidents to patients. We found the medicine division followed the duty of candour policy by providing feedback and investigation outcomes when necessary. Incidents were regularly audited where pressure ulcers, skin integrity, and falls were the most common issues identified. Three incident investigation reports were reviewed, and all included clear action plans. Additionally, the division had been working on an action plan to address delayed complaints, as the trust's target had not been met in 9 of the past 12 months. A thorough investigation was conducted, and steps were taken to improve this.

Patients told us they were informed about potential delays in obtaining a bed space on a ward. As a result, they sometimes had to wait in the corridor until their allocated bed space became available to them. However, while patients told us they felt safe and supported, they experienced sleep disruptions in the corridors due to noise and activity. Patients expressed concerns about privacy without screens but understood the reasons behind this arrangement. During the wait, patients were well-informed about wait times and received regular care from staff. Patients reported minimal corridor wait times for their allocated bed space, typically less than 1 day. Patients told us they were informed of this corridor wait prior to ward arrival and staff conducted risk assessments to ensure their suitability for being there. Patients received regular food and drink whilst waiting and were promptly moved to their assigned bed when this became available.

Staff reported challenges with medical outliers. A medical outlier is a patient who is admitted to a hospital ward that is not their speciality. For example, a cardiac patient requiring a cardiac ward for speciality care might be placed on a surgical ward due to a lack of available beds in the cardiac ward. These patients, often not medically fit for discharge, faced delays in medical reviews and completion of discharge paperwork as the medical teams looking after them were not readily available. This impacted patient flow and delayed discharges. While divisional directors monitored outlier numbers and held meetings to address concerns, repatriation of outliers back to their speciality beds was inconsistent. Therefore, this did not always seem to be effective, as feedback from staff and leaders indicated patients remaining on inappropriate wards for extended periods, hindering efficient patient care and discharge planning. Senior leaders acknowledged the issue and had a plan to increase medical bed capacity to help reduce the number of outliers on non-medical wards.

The trust had clear policies and procedures for patient placement. For example, patients might be boarded in temporary spaces like corridors due to a lack of beds. Pre-empting is the act of transferring a patient for corridor care, if there is a confirmed bed coming up against a definite or 2 potential discharges on the ward. Although not viewed as optimal, boarding and pre-empting was sometimes necessary to manage patient flow and periods of high demand. This will only be against wards which has the capacity to allow this as per Standard Operating Procedures (SOP). A SOP is a clear set of written instructions to support staff to complete a specific task or process. This did not happen overnight. This was discussed at site meetings daily, and risk assessments were carried out with letters provided to patients upon arrival. From January to April 2024, the trust boarded patients on 4 occasions, involving a total of 18 patients. All of these instances adhered to handover processes which were well-defined and followed. An admission, discharge and transfer policy were also available, which had been ratified and reviewed within 1 year as per the trusts agreed process for reviewing trust wide documents. Data analysis revealed no correlation between medical emergencies and patient boarding. No incidents related to boarding were identified in the past 6 months. The discharge lounge was used for escalation on 13 nights between March and April 2024, with 68 patients admitted. No issues or concerns were noted.

Most staff we spoke with had a good understanding of what safeguarding was and felt confident to take action where they had concerns of abuse. Staff gave examples of making safeguarding referrals. They explained there was a mental health team who were easily accessible, and staff knew how to make a referral request. All staff knew signs of abuse and how to escalate concerns.

Staff informed us individualised risk assessments and care plans were developed in collaboration with each patient to ensure their specific needs and preferences were reflected in the treatment plan. This personalised approach aimed to optimise patient-centred care and outcomes.

We observed a Martha’s Rule poster on multiple wards. Martha’s Rule is a patient safety initiative in the NHS that gives patients and their families the right to request a second medical opinion when they have concerns about their condition. This helped to encourage patient involvement where patients could actively participate in care decisions, particularly if they had concerns. The service had processes which encouraged holistic assessments and multidisciplinary working.

The environment followed national guidance and had suitable facilities and equipment for patient care. Clinical waste was disposed of safely. Staff conducted daily safety checks on specialist equipment, and cleaning records showed no gaps.

The staff generally felt safe with the current staffing levels. The Site and Matron's team regularly discussed and addressed any staffing concerns including at the 3 times a day trust staffing call. Ward managers kept staff informed of progress, fostering a sense of being heard. If staff were absent, temporary staff filled shifts, and new employees underwent trust induction and ward-specific orientation. Ward managers held staffing rotas. Ward managers were supportive and encouraged staff development, providing training when available. The service had low vacancies although there were gaps through sickness absence for nursing and support staff. Recruitment and retention initiatives were underway, which staff found helpful. As new employees joined, staff felt less pressured. Staffing levels generally met planned levels. However, due to staffing shortages, staff adapted to provide enhanced care without additional help when needed. For example, patients who required enhanced care were placed in observable bed spaces.

Turnover was monitored and addressed through ‘hotspot’ identification and monthly meetings. As a key performance indicator, turnover was reported at divisional board meetings. The Senior People Advisor followed up on high-turnover departments. Weekly meetings focused on recruitment efforts. Staff were offered support to explore retention opportunities.

The infection prevention and control (IPC) team was co-located with the wider leadership team, improving communication and action on infection control. The team focused on being on wards with staff to emphasize infection control. Previously, the IPC team had monthly focus areas, but feedback led to a quarterly topic for better learning and practice embedding. Staff told us how the infection prevention and control team’s growth and on-site presence since the pandemic had led to improved monitoring and practices. Staff praised the success in reducing Methicillin-Susceptible Staphylococcus Aureus (MSSA) infection rates, feeling proud of the safer patient environment. (MSSA is a type of bacteria often found on the skin and in the nose).

Overall, hand hygiene was satisfactory. However, 1 staff member was observed neglecting to change gloves and aprons. This was promptly addressed, and staff were reminded of infection control protocols. Additionally, unsecured chemicals were found on a medical ward, but this issue was immediately resolved and reported to senior leaders. While cleanliness issues, such as improperly stored incontinence pads next to a macerator were noted in several dirty utility rooms, there was no evidence of patient harm or increased infections. These concerns were also brought to the attention of senior leadership, to ensure ongoing monitoring and oversight.

The service addressed rising MSSA infection rates with action plans and an external audit. The audit identified wounds and cannulas as common infection sources, guiding staff training. Recommendations were shared with ward managers. Weekly quality days included infection prevention and control (IPC) focus. The IPC group met monthly to review infection data, which was shared with the Patient Quality Sub-Committee, Quality and Safety Committee, and Trust Board. An IPC improvement plan was implemented, and progress was positive. Regular infection control audits, including hand hygiene, were conducted. Leaders shared improvements and planned further communications and observations to reinforce good practices.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.