Gloucestershire Royal Hospital
- Regulation
- —
- Date
- 27 Aug 2026
We found a breach of regulation in relation to medicines safety and governance within maternity services.
Regulatory breaches and the formal action the Care Quality Commission took on them, as named in CQC Single Assessment Framework assessment commentary from 2024 onward. CQC publishes no separate machine-readable enforcement register, so each record is the breach statement quoted verbatim from the assessment and classified by the action stated there. A letter of intent is recorded separately from urgent action, so an action CQC is only considering is never shown as one already taken.
Coverage: England. Regulatory breaches and the formal action taken on them, named verbatim in CQC Single Assessment Framework assessment commentary from 2024 onward. Scoped to NHS-trust locations by default, so it is not a complete record of CQC enforcement across the whole regulated estate.
Newest content date: 4 Sep 2026. This describes the content held here, not the date this page was opened.
Records written on 4 of the last 90 days; last write 6 Sep 2026.
Publisher's stated schedule: Continuous. That is the publisher's own description, not a measurement of this copy.
We found a breach of regulation in relation to medicines safety and governance within maternity services.
We identified breach of 1 regulation: 12 Safe Care and Treatment We rated the location as requires Improvement.
We assessed 1 assessment service group at this location to review the progress made following our last inspection in March 2024, where we issued conditions on their registration to improve safety of women and their babies.
During this assessment we found breaches in regulations relating to safe care and treatment and dignity and respect, a warning notice was served.
We found breaches in safe care and treatment, and good governance.
These concerns resulted in a breach of regulation in which we served a warning notice.
We found breaches of the regulations in relation to documentation of mental capacity assessments, mitigation of identified risk, mandatory training compliance and lack of medicines management and good governance.
In addition, it was to review the progress made against the requirement notice that was served to the provider following the inspection in January 2020.
At this assessment we found breaches relating to safe care and treatment and dignity and respect.
There were 3 new breaches in this inspection around long delays, premises and environment.
During the last inspection there were many breaches stating that the trust must ensure to make improvements; we reviewed all these breaches during this inspection, and we found many areas required the improvements had been met.
There were 2 new breaches in this inspection around performance of the stroke pathway and staffing.
There is still a breach of regulation around completion of mandatory training, including safeguarding training, although appraisal rates had improved.
Finally, there was a breach around completion of mandatory and legally required training and staff appraisals.
During the last inspection there was a breach stating that the trust must ensure they continue to work on meeting their referral to treatment targets for all pathways.
We did not see evidence of mixed sex breaches during this inspection.
There was a previous breach around mixed sex breaches.
During our previous inspection of medical care services published in 2024, we identified a breach of regulation relating to completion of risk assessments, with particular attention to venous thromboembolism risk assessments.
We will request an action plan to show how the service will meet the breaches of regulations.
We found 2 breaches of the regulations in relation to safe care and treatment and staffing.
The service had made some improvements since our last inspection, but not all the previous breaches were met.
We identified breaches of 3 regulations around the failure to provide timely treatment, compliance with infection prevention and control guidance, management of substances hazardous to health, not always having safe staffing levels, and improvements needed in governance.
We also issued an action plan request for breaches relating to governance and staffing.
We undertook a follow-up inspection in April 2025 and served a warning notice for breaches relating to safe care and treatment.
The service was in breach of the legal regulations relating to Staffing, Safe Care and Treatment, Consent and Good Governance.
We identified new breaches of regulation.
We found continued breaches of regulations in relation to recording and administration of medicines and the management of patients presenting with poor mental health.
However, we still found breaches in regulations relating to safe care and treatment and safe staffing levels.
This assessment was conducted to follow up on concerns and breaches of regulation identified during our previous assessment published in August 2025.
However, the service remained in breach of 5 regulations related to good governance, staffing, safe care and treatment, premises and equipment and person-centred care.
We found the service had made improvements and had met some of the actions of the warning notices.
We carried out this assessment to review the progress made against a Warning Notice that was served to the trust following the inspection in February 2025.
The service was in breach of the legal regulations in related to safe care and treatment, premises and equipment and staffing.
We found the service was in breach of the legal regulation person-centred care.
At this assessment we identified breaches of regulations person-centred care, safe care and treatment, premises and equipment, good governance and staffing.
The assessment of urgent and emergency care was to review the progress made against a warning notice that was served on the provider following an inspection in February 2025.
They were in breach of the legal regulations in relation to staffing, and safe care and treatment.
We found breaches in safe care and treatment, dignity and respect and good governance.
During our assessment, we found concerns which resulted in a breach of regulation.
We found 2 breaches of regulations in the proper and safe management of medicines and mandatory training .
At this inspection we found breaches of regulation in relation to Safe Care and Treatment and Good Governance.
The previous breach had been addressed, with improvements to medical staff mandatory training rates.
A breach of regulation 17: good governance due to the service not having an audit schedule and staff did not routinely complete local audits.
There was a breach of regulation 12: safe care and treatment due to the design and environment of the maternity assessment unit did not meet the needs of women using the service due to a lack of space for women.
The service was previously in breach of regulation 12: safe care and treatment due to checks not being completed on life saving equipment.
At this assessment we identified a breach of regulations in relation to regulation 12: safe care and treatment and regulation 17: good governance.
There was a breach of regulation 17: good governance due to the service not having an audit schedule and staff did not routinely complete local audits.
We also found a breach of regulation 12: safe care and treatment, we found women did not receive a midwifery review within 15 minutes of arrival within the maternity care centre and women did not receive a medical review within a timely manner.
Following this inspection the service remains in breach of this regulation.
| Category | Value |
|---|---|
| Regulatory breach | 402 |
| Requirement notice | 13 |
| Warning notice | 114 |
| Condition of registration | 2 |
| Letter of intent | 10 |
| Urgent enforcement | 8 |
The chart shows the mix of formal actions named across the loaded records.
Contains public sector information licensed under the Open Government Licence v3.0.