We previously visited the Great Western Hospital in September 2015 when we carried out a comprehensive inspection of the services provided. We raised a number of concerns following this inspection in relation to the emergency department. Our concerns in relation to safety were significant and we judged that the governance systems and processes in place were not effectively operated and, as such, were not able to demonstrate effective management of risks, effective clinical governance, continuous learning, improvements and changes to practice from reviews of incidents, complaints and mortality and morbidity reviews.

In December 2015, in light of these concerns, we took enforcement action and required the trust to make significant improvements. The trust submitted a comprehensive improvement plan and provided us with monthly progress reports.

In April 2016 we carried out an inspection to check progress against the concerns raised in the warning notice. We found that significant progress had been made but the requirements of the warning notice were not fully met. Our remaining concerns were:

• Risks to patient safety were not always addressed in a timely way.

• Accurate and up-to-date records of care and treatment were not consistently maintained to ensure that patients were protected against the risk of inappropriate care and treatment.

• Staff did not consistently comply with safety systems in place to identify seriously unwell or deteriorating patients.

• The emergency department was not consistently staffed to ensure that defined safe staff to patient ratios were met. There was insufficient reporting or scrutiny of staff concerns with regard to staffing levels and capacity.

• We had continuing concerns about the safety of patients and staff in the emergency department observation unit. Plans to relocate or reconfigure the unit to improve safety had not been finalised.

• There remained a significant number of gaps in nurse training. A training plan to address identified gaps had not been developed and management oversight of this had yet to be implemented.

In October 2016 we conducted a second follow up inspection of the emergency department. At the time of this visit, we were aware that the emergency department and the hospital had continued to experience unprecedented demand for unscheduled care. This was reflected in the trust’s performance against key targets. In the period July to September 2016 the trust consistently failed to meet the following targets:

• 85% of patients were triaged within 15 minutes of arrival (patients arriving by ambulance) against a target of 95%;

• The median time patients waited to be seen was 70 minutes, compared with the target of 60 minutes;

• 80.1% of patients were discharged, transferred or admitted within four hours, compared with the target of 95%.

We found that further and sufficient progress had been made to meet the requirements of the warning notice. Our key findings were as follows:

• Record keeping had improved through ongoing training and coaching. Audits showed an improving picture in relation to the frequency with which staff observed patients’ vital signs and calculated early warning scores to identify deteriorating patients.

• There was improved oversight of staffing, capacity and safety in the emergency department by the nurse in charge. Regular situation reports had been introduced and these ensured managers were informed of risks and concerns were escalated. Steps were being taken to reduce the risks associated with the employment of temporary staff. The department was exploring innovative ways to improve staff recruitment and retention.

• Governance systems had been further strengthened. Risks were well understood and regularly discussed. Audits were used to drive service improvement. There was greater oversight of nurse staff training and supervision.

• Steps had been taken to better equip staff to care for mental health patients on the observation unit. Plans had been agreed to make alterations to the premises to create a safer environment for patients and staff. Incidents relating to the management of mental health patients had reduced significantly.

However, there were also areas where the trust needs to make further improvements:

• We had continuing concerns that the emergency department was not able to consistently meet defined safe staff to patient ratios at times of overcrowding. Staff shortage was a continuing problem and there were concerns about a lack of senior and experienced nursing staff. There was heavy reliance on temporary staff and there were concerns about their competence. Notwithstanding the risk this posed to patient safety, this affected staff morale, recruitment and retention.

• We were concerned about a lack of pace in addressing risks identified by a serious incident which occurred in May 2016. We were also concerned that learning had not been embedded in staff practice following a similar incident which occurred in 2014. Staff awareness of risks and learning from adverse events needed to improve.

• Despite improvements in record keeping, we judged there was room for further improvement and consistency, to ensure that patients are protected against the risk of inappropriate care and treatment.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Great Western Hospital, Swindon, is part of Great Western Hospitals NHS Foundation Trust. We visited the hospital to review improvements the trust told us it had made to staffing levels in its maternity services. On our previous inspection of maternity services at this location in December 2012, we found staffing levels in relation to midwives were not always at acceptable levels to safely meet the needs of patients.

The trust sent us a series of action plans to outline how it was going to improve in these areas. We went back to the maternity department at the hospital to check on progress, and ask patients about their care and experiences of the service.

All the patients we met on this visit were pleased with the care they had received. One parent we met said: "without this hospital, I would not have a family." A family who had attended the maternity department on a number of occasions said: "we've always had good care. We can't really fault the place. The consultant treating us was 'world class'." Another patient said: "the care's been fantastic. Everyone's always helped." We were told by a patient: "I would recommend coming here to anyone." One family said the staffing levels in the daytime were "fine" but there seemed to be less staff available at night and "then they seem to be flat out." They said staff came, however, at all times and whenever they needed them, and said: "my faith in hospitals has been fully restored by this experience."

We found the trust had made sufficient progress in a number of areas to improve the staffing levels and skill mix. This included the women’s and children’s directorate raising the profile of this area of concern with the executive committee; the changing of staff shift patterns; recruiting additional staff; validating the model for determining safe staffing levels in maternity services; and putting in place an escalation policy for dealing with unplanned acute shortages of staff.

We visited Great Western Hospital, Swindon, on 5 July 2012. We visited to review improvements the trust told us it had made in two areas of concern that arose from our inspection in December 2011. The trust had developed action plans to address these concerns. These plans were provided to us following our previous inspection.

We were accompanied on this inspection by the interim chief nurse.

We visited two wards in the hospital where, in December 2011, we were concerned about patients not having enough to drink, or this not being accurately recorded. We met and talked with patients on these wards and with the nursing and care staff on duty. A number of the patients we met were older people, some of whom were assessed as needing protection from the risks associated with poor hydration. The patients we met told us they were being given enough to drink and said staff had told them why it was important to take enough fluids.

We asked patients about their overall care at the hospital. One patient said: “care here is fabulous” and another said: “nothing is too much trouble”.

The staff we met on our visits to the wards showed dedication, professionalism and a caring attitude to patients. We found evidence to judge the hospital had made significant improvements to providing and monitoring fluids. Patients were being protected from the risks of inadequate hydration.

We went on to visit the operating theatres’ department where, in December 2011, we were concerned about the safety of theatre procedures and team communication. Great Western Hospital had 15 operating theatres to carry out elective, emergency or trauma surgery. Emergency and trauma theatres were set up to operate 24-hours-a-day. We met and interviewed members of the surgical team on duty during our inspection.

We focused at this visit upon use of the surgical safety checklists and associated protocols and procedures. Staff told us the use of checklists, surgery briefings and debriefing sessions had been re-launched within theatre. Staff said communication had “significantly improved” within teams. All members of the team felt valued and supported to deliver safe and quality care.

The action plan provided to address concerns in theatre practices following our inspection in December 2011 was extensive and detailed. All concerns were addressed in detail and actions allocated to a responsible member of staff.

The staff we met and interviewed in theatre demonstrated professionalism, knowledge and dedication to their respective roles. Patients were adequately protected from the risks of unsafe treatment during surgical procedures.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that treatment for the termination of pregnancy was not commenced unless two certificated opinions from doctors had been obtained.

We visited the hospital to look at the improvements made in connection with three main areas:

• The use of ‘extra bed spaces’. These were additional beds which were being used, for example, to provide a fifth bed in a room designed for four people.

• The monitoring of fluid intake in relation to those patients who were at risk of dehydration if they did not receive the appropriate support.

• The occurrence of two ‘never events’. Never events are defined as ‘serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented’.

These areas were not directly related, but they were matters that the Trust had responded to by producing action plans with the aim of improving outcomes for patients.

We had heard adverse comments from patients about the extra bed spaces during our two previous visits to the hospital. The Trust has since carried out work to improve the facilities; however we were told that the use of extra bed spaces continued to cause difficulties for both patients and staff. Patients did not feel they were being treated on an equal basis and staff said that they received a lot of complaints.

We had been informed of two never events in recent months involving surgical procedures. One of these was a ‘wrong site’ event and the other involved the ‘wrong implant’ (a lens). During our visit we were told about the action being taken to reduce the risk of people being involved in surgery related never events. However, patients could not yet be confident that the appropriate preventative measures were being consistently implemented.

Patients’ fluid intake was not always being well monitored when we visited the hospital in July 2011. There was a risk that some patients were not receiving the support they needed with hydration. We looked at this again during the visit on 8 December 2011. The staff we spoke to were aware of the importance of monitoring people’s fluid balance, although there continued to be shortcomings in how this was being managed.

People’s experiences of the hospital were mostly very positive. They told us that they were kept informed about their care and treatment. People felt that staff treated them with dignity and respect. In the outpatient department, for example, someone said that they were never made to feel uncomfortable. However, not everyone in the hospital experienced the same degree of choice, privacy and independence.

People’s needs were being assessed to make sure that they received the right treatment. Staff were described as ‘very helpful’ and ‘very professional’. One person commented ‘nothing is too much trouble, all care is given with a smile’.

Most people were happy with the meals. Staff helped people with their food and drinks. However, it was not always clear whether people had received the amount that they needed. People’s records did not always give a good or accurate picture of their care needs.

People experienced consistent care because the trust made arrangements with other providers and shared information. Medicines were being well managed and some people could look after their own if it was safe to do so.

People thought that the hospital was kept clean and they liked the modern surroundings. They said that the hospital was well equipped, although we found that items of medical equipment were not always being promptly serviced.

People said that they felt safe and there were usually enough staff on the wards. However staff were often busy, which meant that people might have to wait longer than they wanted to. One person commented ‘sometimes the nurses are rushed, but they are always polite and courteous’; other people expressed the same view.

Staff received a lot of training and worked as a team, which helped people to feel well cared for. Some staff worked on a relief basis; they did the same job, but they did not always receive the same level of support.

People felt that they could talk to staff if they had any concerns. The hospital had produced a lot of information and was keen to get feedback. However, people were not always aware of this information, and hadn’t always been told how they could pass on their views.

Overall, people felt that the hospital was meeting their needs well. The trust looked closely at its own performance to see how the service could be improved further.

Patients we spoke with made some very positive comments about the staff. They described staff as ‘very kind’, ‘lovely’ and as treating them ‘like a friend’. We were told that staff were busy and worked hard, and some patients said that more staff were needed.

Patients told us that staff took an interest in how they were feeling. However, they had not always been asked for information which would help staff to get to know them as people, with their own likes and dislikes.

We were told about the layout of the wards, which included a number of single rooms with en-suites, and other rooms for four patients. Patients liked the privacy and the facilities that these areas provided. However, we also met patients who said that their privacy and dignity was not being respected. One person described themselves as a ‘trolley patient, the fifth person in a four bedded room', as they were accommodated in an extra bed.

We heard positive comments about the choice and quality of meals. Most patients were satisfied with the meal arrangements. However, we were told about shortcomings, such as when a person got a meal that they hadn’t asked for, or felt that they needed more support.

Our rating of services stayed the same. We rated them as requires improvement.

A summary of services at this hospital appears in the overall summary above.