Concerns had been raised with us about the staffing and medicines management of one ward at the hospital. This ward was opened in January 2013 in response to the demand for additional beds during the winter months.

During this visit to check these concerns we spoke with 17 patients, three of their relatives and 12 staff. All patients and their relatives told us they were happy with the care provided to them and staff treated them well. Some patients told us, “very good, very helpful”, “lovely staff” and “absolutely fine, no complaints at all”. We observed staff interacting with patients in an attentive and respectful manner.

Overall we found that there were enough qualified, skilled and experienced staff to meet patient’s needs and the care and treatment provided met patient’s needs. Where concerns about patient safety and staffing levels had been reported appropriate action was taken to learn from the incidents and minimise the risk of re-occurrence.

Appropriate arrangements were in place in relation to obtaining and the recording of medicines. Suitable arrangements were not in place for the storage of all medicines because some cupboards were unlocked at the time of our inspection and some could not be safely secured. This increased the risk of medicines being accessed by unauthorised people and could cause harm to them or others.

During this inspection to check improvements to record keeping we looked at patient medicine administration and care records on four wards. We looked at the electronic staff rota system and spoke with staff on two wards about the staffing levels.

The pharmacist inspector looked at 27 patients’ medicines prescription and administration records on two wards previously visited. We found that significant improvements had been made although we still saw occasional gaps on these records. We looked at the care records for 30 patients to check the patient profile forms (these recorded a daily assessment of a patient’s needs). We found that apart from two records all had been completed on the day of our visit to reflect the needs of the patients.

We saw that the electronic staff rota system had been updated and implemented on more wards since our last visit. We saw that in most instances the electronic system was updated to reflect changes to staffing as they happened. Where it was not possible to update the electronic system to reflect staff changes, paper records of staffing levels were held on individual wards.

Overall, we found records for the administration of medicines and care records had improved and were mostly being accurately kept. We also found that when paper records were looked at in conjunction with the electronic system we could see that the trust knew where staff were working and the staffing levels of each ward.

Seven CQC Compliance Inspectors, a CQC Pharmacist and an Emergency Department expert spent four days in July 2012 visiting Cheltenham General Hospital. We spoke with 118 staff, one volunteer, 87 patients and some relatives and visitors. We visited 14 wards, the oncology outpatients department, the discharge waiting area, the Patient Advice and Liaison Service (PALS) and the Emergency Department.

We met and talked to inpatients and outpatients, hospital directors, senior management, health care assistants, physiotherapists, domestic staff, nurses from all divisions of the hospital, administration staff, a consultant and doctors. We saw and were given evidence from hospital records, audits, surveys and trust board reports. This enabled us to see how the hospital had been assessed against the essential standards of quality and safety. We reviewed our visit with Dr Frank Harsent (Chief Executive Officer of the trust) and five other board members on July 31 2012.

Patients told us that staff treated them with dignity and respect and addressed them by the name of their choice. Patients also told us that both the medical and nursing staff told them about their treatment choices and kept them informed about their progress and any changes to their treatment. Patients' made the following comments to us about their care and treatment, “wonderfully organised and they kept me informed of my plan for being discharged”, “very good”, “brilliant, so good and staff have been really kind”, “I cannot fault them here” and “with the person next door to me, who has Alzheimer’s disease, they have never lost their patience with them”.

We looked at seven of the essential standards of quality and safety. We found them compliant with six of the essential standards and we have minor concerns with one of the essential standards. More detailed information on each of the essential standards is covered in other parts of our report under the relevant Outcomes.

• In urgent and emergency care, staff received appropriate training in safeguarding and mandatory skills. Infection risk, records and medicines were managed well. Risk assessments were completed where necessary and patients were seen in a timely way. The department performed positively against other hospitals. Staff worked well together to provide effective care. The patient remained at the centre of this, by staff ensuring they delivered care compassionately, provided emotional support where needed and involved carers and families. Flow through the department was positive, and the four-hour target was consistently met. Governance was positive, and information was used to support its activities.
• Staff in medical care understood how to protect patients from abuse, completed relevant risk assessments and kept clear and legible records of patient care. The effectiveness of the service had improved since the last inspection. The medical care service met the needs of people it supported. We found the leadership, governance and culture in medical care supported the delivery of high-quality care.
• Staff in surgical services understood how to protect patients from abuse and the service worked with other agencies to do so. Staff completed and updated risk assessments for each patient. The surgical division participated in both national and local audits to monitor people’s care and treatment outcomes and compare with other similar services. All staff were committed to providing excellent care to their patients. Quality improvement projects had helped to improve the service being delivered to patients, however some projects were in their infancy.
• Staff in outpatients understood how to protect patients from abuse and there were clear processes for reporting safeguarding concerns. There were systems in place to manage maintenance of equipment and repair faults when identified. Staff kept appropriate records of patients care and treatment. The service made sure staff were competent for their roles. Patients were treated with compassion, kindness, dignity and respect throughout their visits to outpatient services. Staff within outpatients worked hard to ensure people with learning disabilities were able to access services. The trust identified where a system-wide approach was needed to meet the needs of the local population. Staff supported patients with additional needs such as patients living with dementia. The trust had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. There was a positive culture within outpatient services. The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff and patients.
• We found the service had improved, but the surgical division still needed time to embed processes and practice, and improve certain areas, under new leadership. Staff understood how to protect patients from abuse and staff completed and updated risk assessments for each patient. There were processes to recognise and respond to a deteriorating patient. A sepsis care bundle was used for the management of patients with presumed or confirmed sepsis. The World Health Organisation (WHO) surgical safety checklist was used in theatres. The surgical division participated in both national and local audits. All staff were committed to providing excellent care to their patients. Quality improvement projects had helped to improve the service being delivered to patients, however some projects were in their infancy.
• Although we found the surgical service was improving, the division still needed time to embed processes and practice, and improve certain areas, under new leadership. Medical gas oxygen cylinders were not being stored securely across surgical wards and theatres. Staff required some additional support to manage patients living with mental health needs safely. Staffing on wards was regularly at minimum staffing levels rather than at funded establishment, particularly at night times. A shortage of radiologists made it difficult to provide 24-hour cover. Staff demonstrated a limited understanding of the Mental Capacity Act. Systems used by the trust did not help promote flow and efficiency in theatres and risked the safety of patients.

However:

• In urgent and emergency care, we found that although staffing levels were maintained, there was an over-reliance on bank and agency staff. We also found that there could have been better publicity of the emergency departments opening times.
• In medical services systems and processes to keep people safe were not always followed in relation to infection control and medicines management. Performance in national audits was variable and outcomes for stroke patients needed improvement. The responsiveness of the medical service required improvement as national targets for referral to treatment times were not met for most medical specialities and the trust was not producing reliable data on referral to treatment times. In well-led, risk management processes needed to be improved as risks were not always graded, mitigated and reviewed appropriately.

• In surgical services, oxygen cylinders were not being stored securely across the service. There was also a training need for staff around managing patients living with mental health needs. We found that staff felt they were stretched and overworked. This affected their wellbeing. Understanding of the mental capacity act could have been better and some support services, such as radiology were not part of formal rotas. Patients were not always able to access services in a timely way and systems used did not promote positive flow through theatres.

• Outpatient services were primarily a five-day service. Lack of space was identified as an issue in certain clinic areas. The introduction of a new patient appointment booking system, had presented a number of difficulties in the delivery of services. The trust has been unable to report referral to treatment data to NHS England since November 2016 because of data quality issues following the introduction of a new electronic patient record system in December 2016. Patients could not always access services when they needed them.