24 May 2024, 8 a.m.

The Care Quality Commission (CQC) has published two reports for the Trust’s Children’s Centre and Emergency Department. They have also issued an enforcement notice on Maternity Services.


The reports can be viewed on the CQC website

Children’s Centre CQC Inspection Report - September 2023

In September 2023 the Trust contacted the CQC and request support and guidance in relation to the provision of care for young people within the hospital, who should be placed in an appropriate placement setting for their needs.

The CQC responded to this request and carried out an unannounced focused inspection of the Children’s Centre to look at the safety and quality of the service, specifically for young people with complex psychosocial needs.

The concerns raised to the CQC by the Trust related to the care of young people with complex psychosocial needs on our children’s ward.

We informed the CQC that we had patients who were ready for discharge, but sadly remained inappropriately placed at the hospital due to lack of capacity in more appropriate settings, with no clear discharge pathway.

We also raised the concern that, in order to keep the patients and other children on the unit safe, the occasional use of physical restraint and administration of emergency sedation was required.

This is something that is distressing for everyone involved, and the Children’s Centre was not the right setting to be providing the specialist care needed.

Following the inspection, the CQC raised a number of areas of improvement for the Trust:

  • The privacy and dignity of young people receiving care could sometimes be compromised.
  • Care plans and records did not always reflect national guidance.
  • Staff had not completed all mandatory training.
  • Concerns over the competencies of registered nurses supplied by an agency to provide specialist mental health care.
  • The Trust’s medicines policy and procedures around emergency sedation were not always followed.

However, the CQC noted that:

  • Staff were responsive when caring for young people.
  • Staff took time to interact with the young people in a respectful and considerate way outside of clinical interventions.

Following the CQC inspection, the team have strengthened processes around appropriate hospital admissions, administration of emergency sedation, reviewed mandatory training and strengthened recruitment and use of Registered Mental Health Nurses.

The report is challenging and we recognise the patients at the heart of the Children Centre inspection should not have been in our hospitals, which is why the Trust took the decision to proactively raise the safety concern and seek support from the CQC.

Urgent and Emergency Care CQC Inspection Report - December 2023

In December 2023 the CQC conducted unannounced focused inspections of Urgent and Emergency Care at Gloucestershire Royal Hospital.

The inspection looked specifically at the safety of the services following concerns raised to the CQC around cleanliness, however during the visit it was noted that the areas were clean. They also noted that there had been a small electrical fire in the department, but fire exits were blocked.

As a result, the CQC served a 29a Warning Notice on the service to make rapid and widespread improvements in fire safety to keep people safe, and the department was again rated as requires improvement.

Key findings in the CQC Report:

  • Staff were not following national regulation and guidance in relation to fire safety.
  • There were systems and processes in place to report and learn from incidents however local fire procedures were poor despite the recent fire in the department.
  • Medical devices were not being tested in accordance with national regulation and guidance.

However, the CQC noted that:

  • Although staff completion rates of infection prevention and control training were low, this improved in January 2024 following the inspection.

Since the inspection in December 2023 the Trust has completed a number of actions, including updating the fire plan and detailed planning for a full departmental fire evacuation for the new Emergency Department at Gloucestershire Royal Hospital.

In addition, the services have completed refresher training for all designated fire wardens and increased mandatory training for fire safety for all staff across the department.

The Trust has reviewed and increased signage for fire exits and all fire exits are checked three times per shift and documented in shift reports.

All Medical Devices will continue to be regularly tested and a register maintained by the Patient Safety Lead within our Emergency Department.

Maternity Services CQC Inspection March 2024 – Enforcement Notice

The CQC visited Maternity at Gloucestershire Royal Hospital to carry out an inspection on 26 March 2024 and the report is expected in the summer.

The initial feedback was that there were no immediate safety concerns and improvements had been made in the culture within the department. However, there was a need to strengthen reporting processes and evidence of learning.

On 9 May the CQC issued an enforcement notice, putting a number of reporting conditions in place to ensure focused attention and improved pace, including:

  • Stronger systems to provide and up to date and overarching view of quality and safety across the maternity service;
  • Systems and processes to identify and action timely identification and learning from incidents across all teams in the department.

These include immediate actions that the Trust is expected to take and the service is required to report progress to the CQC on a monthly basis.

There will also be additional system oversight and coordination in place through this next period, so we can ensure that improvements that need to be made are embedded.

The service is also reviewing internal process so there is an effective system of governance, aligned to Board reporting, to ensure improvements, including oversight of themes and trends from incidents and learning is acted upon and shared in a timely way.

CQC Next steps

The Trust expects the CQC to re-inspect the services in the near future and will be working with colleagues and partners to ensure improvements are made.

More information

If anyone has any concerns they can contact the Trust's Patient Advice and Liaison Service (PALS)