Gloucestershire Royal Hospital

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We assessed 2 quality statements in the well led key question, freedom to speak up and governance. We found 2 breaches of legal regulations in relation to governance. The assessment of these areas indicated areas of concern since the last inspection and our rating for the key question remains inadequate. Monitoring of performance, incidents, complaints and audits were completed in a way that did not identify where improvements could be made to reduce patient risk. Information was not always shared effectively with staff resulting in learning not being identified or embedded in practice. Processes for ensuring agency staff were familiar with and had access to trust systems without delay had been paused and were not being effectively monitored. This could delay care and treatment provided to people who used the service. Some staff had poor experience when raising concerns. However, there were processes for staff to speak up. New processes had been implemented to improve opportunities for staff to raise concerns. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff experience of speaking up was not always positive. Some staff had not always felt supported or treated with compassion when they had raised concerns. Concerns some staff had raised were taking a long time to be actioned and completed. However, Staff knew how to raise concerns and many staff were happy to raise concerns with their line manager or freedom to speak up guardian.

A range of methods were available for staff to use in raising concerns. Any staff concerns raised were monitored for themes. Senior staff were creating additional methods for staff to raise concerns. Safety Champions for maternity had started a programme of attending all areas of the maternity service. This was to work alongside and engage with staff to gather their views and create a more open culture. Freedom to speak up guardians were available for staff and contact details were shared. When staff raised concerns they were investigated and there was a process for providing staff with feedback. However, we saw some processes had taken a long time to complete.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Managers described audit processes used to monitor how well systems were working. However, the results were not managed effectively. Managers reviewed audit results and were aware of risks which had been highlighted in previous months but had not taken immediate actions to mitigate the risks. This led to the potential for risk of deterioration in patients’ conditions not being escalated for senior review as soon as it should be. Managers and staff were clear about their roles and described a process they felt was effective. There was a range of committees which reviewed performance data, incidents and complaints. Managers told us they created action plans based on their review and monitored these until actions were completed. Managers had started to use relevant quality frameworks, and national standards for best practices or equivalents. These were aimed at improving experience and outcomes for all people using services and to tackle known inequalities. The trust was part of the Local Maternity and Neonatal System (LMNS). This is where trusts from the same region link together to improve services, to make them safer, more personal, and kinder to people who use them. Senior staff linked in with Maternity Voices Partnership, to learn from experiences of women and their family.

Risks for people who used the service were often not identified. Audit processes were not effective and did not provide the best information about risk, performance and outcomes. Some audits were not completed frequently enough and learning was not being identified in a timely way. Sharing learning with staff was often delayed with no immediate actions taken. Post-partum haemorrhage rates (a life-threatening complication of pregnancy) were continuing to rise when compared with previous months. Audits had identified delays in escalating deteriorating patient conditions. On the 4 occasions when consultants had not attended complex clinical situations when national guidance stated they must attend, women were being cared for by obstetric and midwifery staff but with limited senior support. The Royal College of Obstetricians and Gynaecologists (RCOG) risk assessment tools were used but not always in their entirety and missed some of the risks for mothers and babies. Data reported to the NHS Digital maternity dashboard showed some outcomes similar to or better than national averages. However, 4 were worse than national averages and we saw no evidence of learning or improvement in response to these metrics. Learning from incidents was not always identified and shared in a timely way. Major obstetric haemorrhage incidents had been discussed at the monthly Delivery Group meeting 2 months later. Staff who undertook investigations had not all received relevant training for the role. There were some improvements from actions taken but they were not always sustained in practice. Triage times for women being seen by a midwife had improved. There was no assurance all risks for the service were included in the risk register. Managers used processes to review information and identified need for additional resource in governance. A new role for overseeing governance processes had been recruited to. Staff compliance with training in mandatory skills for their role had improved.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.