Source · CQC inspection

Gloucestershire Royal Hospital

Provider Gloucestershire Hospitals NHS Foundation Trust Type NHS Healthcare Organisation Region South West Last inspected 13 Nov 2024

Overall rating: Good View full CQC report

Domain ratings

Five CQC key questions

Safe

Good

Effective

Good

Caring

Good

Responsive

Requires Improvement

Well-led

Good

Current CQC assessment

Single Assessment Framework

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

Good Assessed 13 November 2024

The service is performing well and meeting our expectations.

Date of assessment 26 March to 7 May 2024. Gloucestershire Hospitals NHS Foundation Trust provide a maternity service for women in Gloucestershire. We conducted an evidence-based, desk top assessment of the hospital. The assessment also included an onsite visit on 26 March 2024. This assessment was to follow up on actions we told the trust to take in a previous inspection and in response to concerns raised with us more recently. We assessed a total of 5 quality statements from the safe and well led key questions and found areas …

Ratings by service

Urgent and emergency services

Requires Improvement

Dec 2023

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 (3)

Breach Overall

We found 2 breaches of legal regulations in relation to governance which impacted on care and treatment.

· 7 Jan 2025

Breach Overall

We found 2 breaches of legal regulations in relation to governance which impacted on care and treatment.

· 13 Nov 2024

Breach Overall

We found a breach of legal regulation in relation to equipment and premises which impacted on care and treatment.

· 13 Nov 2024

Earlier inspection findings

pre-2024 framework · 3 must-do 4 should-do

Must-do actions (3)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 3

Must do

Safe

The trust must ensure that the intercollegiate guidance for safeguarding children and young people on safeguarding training is followed regarding staff training.

Regulation: Regulation 13(2)

⚠ Training records showed level 3 safeguarding training was below 50% and not all staff had received training on the mental health needs of children and young persons. Not all staff were trained to safeguarding level 3 for children and young persons. A review of the training records indicated that, as …

Must-do action 2 of 3

Must do

Safe

The trust must ensure that staff follow trust policies and procedures when administering medications.

Regulation: Regulation 12(2)(g)

⚠ The trust medicines policy and procedures regarding the administration of emergency sedation and the observations of the patient post administration were not being followed. Staff were not following the national guidance on the use of emergency sedation in a child or young person. Managers did not have a comprehensive oversight …

Must-do action 3 of 3

Must do

Caring

The trust must ensure steps are taken to protect the privacy and dignity of children and young people in their care.

Regulation: Regulation 10(1)

⚠ The gender of the staff undertaking the enhanced observations did not always reflect the gender of the young person. There was no privacy in the young persons’ rooms, and we were told that de-escalation and restraint took place in the rooms. People moving along the corridor could see into the …

Should-do actions (4)

Recommended improvements to enhance service quality.

Should-do action 1 of 4

Should do

Caring

The trust should ensure when observations are being undertaken, the gender of the staff observing should reflect the preferences of the young person.

Regulation: Regulation 10(1)

Should-do action 2 of 4

Should do

Safe

The trust should ensure care plans reflect national guidance for restraint, observation, and emergency sedation.

Regulation: Regulation 12(1)

Should-do action 3 of 4

Should do

Safe

The trust should ensure all staff involved in the management of violence and aggression receive training on how to complete patient records. This should include what information is required to be documented following restraint and use of rapid sedation as detailed in the Nice Guidance for Violence and Aggression: short-term management in mental health, health and community settings and the Mental Health Act Code of Practice 26 Safe and therapeutic response to disturbed behaviour

Regulation: Regulation 13(4)

Should-do action 4 of 4

Should do

Effective

The trust should ensure that the young person is involved, wherever possible, in the planning of their risk management plan, considering any advanced statements by the young person, and that the young person is involved in the post incident debrief.

Regulation: Regulation 12(1)