Source · CQC inspection

Great Western Hospital

Provider Great Western Hospitals NHS Foundation Trust Type NHS Healthcare Organisation Region South West Last inspected 25 Jul 2025

Overall rating: Requires Improvement View full CQC report

Domain ratings

Five CQC key questions

Safe

Requires Improvement

Effective

Good

Caring

Requires Improvement

Responsive

Good

Well-led

Good

Current CQC assessment

Single Assessment Framework

From 2024 CQC rates services through ongoing assessments rather than comprehensive inspections.

Requires Improvement Assessed 25 July 2025

The service is not performing as well as it should and we have told the service how it must improve.

Great Western Hospital NHS Foundation Trust provides a range of NHS hospital services. This assessment looked at Surgery services which we rated as good and Urgent and Emergency services which we rated as requires improvement. The rating from surgery and urgent and emergency care has been combined with ratings of the other services from the previous inspections. See our previous reports to get a full picture of all other services at Great Western Hospital NHS Foundation Trust. The rating of Great Western Hospital NHS Foundation Trust remains requires improvement. 

Ratings by service

Surgery

Good

Jul 2025

Urgent and emergency services

Requires Improvement

Jul 2025

Surgery

Good

Feb 2025

Urgent and emergency services

Requires Improvement

Feb 2025

Medical care (Including older people's care)

Good

Sep 2024

Regulatory breaches & enforcement

Current-framework "must do" equivalent

Breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, stated verbatim in the CQC assessment.

Breaches identified (2)

Breach Overall

There were improvements following the breaches reported in the previous inspection of surgery in 2020.

· 25 Jul 2025

Breach Caring

The service was in breach of the legal regulation relating to safe care and treatment, dignity and respect and governance.

Regulation: Regulation 10 (Dignity and respect) · 25 Jul 2025

Earlier inspection findings

pre-2024 framework · 5 must-do 2 should-do

Must-do actions (5)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 5

Must do

Safe

The service must ensure staff are up to date with maternity mandatory training modules. Including safeguarding training level 3 for both adults and children

Regulation: Regulation 12(1)(2)(c)

⚠ Not all staff had sufficient training to recognise and protect women and birthing people from abuse. Compliance for adult safeguarding level 3 ranged from 0% to 46% and children's safeguarding level 3 from 40% to 75% across different staff groups. Compliance for adult life support level 2 was 64% and …

Must-do action 2 of 5

Must do

Safe

The service must ensure that triage processes are safe, risk assessments are carried out, and women and birthing people have access to parity of service at any time of day or night.

Regulation: Regulation 12(2)(a)(b)

⚠ Women and birthing people were not always assessed in a timely way, and their care was not prioritised according to clinical need. Staff did not always complete risk assessments in triage, and SOPs were not consistently followed. Audits showed low compliance (15-45%) with seeing women within 15 minutes of arrival …

Must-do action 3 of 5

Must do

Well-led

The service must ensure non-compliant audits are acted upon and improvement plans put in place.

Regulation: Regulation 17(2)(a)

⚠ Repeat audits were not always undertaken even when the outcome was non-compliant. For example, an SBAR handover audit showed compliance in only 2 of 20 items, but re-auditing was delayed. An OASI audit showed 6 of 11 questions were non-compliant, with re-audit results unavailable.

Must-do action 4 of 5

Must do

Safe

The service must ensure incidents are managed well, including but not limited to effective sharing of learning, using learning to effect change and improvement in practice, ensuring incidents are categorised, harm rated, investigated, referred for external review and reported accurately and appropriately.

Regulation: Regulation 17(2)(a)(b)

⚠ The service did not manage safety incidents well. Staff underreported incidents (e.g., PPH), and incidents were often inappropriately harm-rated (e.g., OASI downgraded from moderate to low/no harm) or incorrectly categorised. Learning from incidents was not always timely or effectively shared, and it was unclear if appropriate referrals were made to …

Must-do action 5 of 5

Must do

Safe

The service must ensure that adequate documentation takes place including but not limited to triage arrival times and assessments, consistent use of SBAR, consistency and accuracy over several record-keeping systems.

Regulation: Regulation 17(2)

⚠ Staff did not always keep detailed and fully completed records, including post-delivery suturing, triage arrival times and assessments, partograms, and CTG records. There was a lack of clarity for staff due to multiple, non-integrated paper and electronic record-keeping systems, leading to inconsistencies and difficulty finding information. The service did not …