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Gloucestershire Royal Hospital

Provider Gloucestershire Hospitals NHS Foundation Trust Type NHS Healthcare Organisation Region South West Last inspected 27 Aug 2026

Location rating: Requires Improvement  View location on CQC

Location ratings by domain

Five CQC key questions

Ratings held for this CQC location under the Single Assessment Framework, assessed 27 August 2026. Ratings extracted from individual reports are shown separately below.

Safe
Requires Improvement
Effective
Requires Improvement
Caring
Good
Responsive
Requires Improvement
Well-led
Requires Improvement

CQC assessments indexed

Single Assessment Framework

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

Requires Improvement
The service is not performing as well as it should and we have told the service how it must improve.
We assessed Gloucestershire Royal Hospital maternity unit and the community from 8 to 17 September 2025.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. We found that the service had made improvements.Gloucestershire Royal Hospital is part of Gloucestershire Hospitals NHS Foundation Trust, they were registered with CQC in April 2010 to deliver the regulated activities: Assessment or medical treatment for persons detained under …

Ratings by service

Medical care (Including older people's care)
Good
Sep 2025
Urgent and emergency services
Requires Improvement
Sep 2025
Maternity
Requires Improvement
Jun 2025
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.

Condition of registration Overall
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.
· 27 Aug 2026 · CQC source
Condition of registration Overall
We issued 8 conditions on their registration to improve the safety of women using maternity services.
· 27 Aug 2026 · CQC source

Breaches identified (11)

Breach Overall
At this assessment we identified 2 breaches of regulation.
· 27 Aug 2026
Breach Safe
The second breach was in relation to Premises and Equipment.
Regulation: Regulation 15 (Premises and equipment) · 27 Aug 2026
Breach Overall
We found 8 breaches of regulation where care and treatment were not always provided in a safe and timely way in line with clinical guidance.
· 27 Aug 2026
Breach Overall
We have asked the provider for an action plan in response to these breaches.
· 27 Aug 2026
Breach Overall
We found a breach of regulation in relation to medicines safety and governance within maternity services.
· 27 Aug 2026
Breach Safe
We found 1 breach of regulation in relation to safe care and treatment.
Regulation: Regulation 12 (Safe care and treatment) · 27 Aug 2026
Breach Safe
We identified breach of 1 regulation: 12 Safe Care and Treatment We rated the location as requires Improvement.
Regulation: Regulation 12 (Safe care and treatment) · 27 Aug 2026
Breach Safe
The first breach of regulation was in relation to Safe Care and Treatment where staff did not conform with the trust’s infection control measures for hand washing and being bare below the elbow.
Regulation: Regulation 12 (Safe care and treatment) · 27 Aug 2026
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

Most recent report indexed for actions

The date and rating here are from an individual report, not necessarily the location's latest assessment. Report ratings are extracted with AI; verify the original PDF.

Type: Location
Date: 23 May 2024
Rating extracted from this report: Inspected but not rated
Actions indexed: 3 must-do 4 should-do

Read this inspection PDF

AI-extracted 3 Jun 2026

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)