Gloucestershire Royal Hospital

Registration details

The location ID for Gloucestershire Royal Hospital is RTE03.

CQC register Gloucestershire Royal Hospital to carry out these legally regulated activities. Contact us if you think Gloucestershire Royal Hospital is operating services not listed here.

Type of service

• Hospital

Service specialism

• Services for everyone

Local authority

Gloucestershire

Monitored services

CQC register Gloucestershire Royal Hospital to carry out the following legally regulated services here:

Maternity and midwifery services

Mr Kevin Luke McNamara is responsible for these services.

Condition of this registration relating to carrying out this regulated activity

1. The registered provider must implement an effective system for ensuring staff at Gloucestershire Royal Hospital continually risk assess and manage the risk of post-partum haemorrhage (PPH) and potential major obstetric haemorrhage (MOH).

2. The registered provider must ensure maternity staff at Gloucestershire Royal Hospital complete hourly peer reviews (also known as ‘fresh eyes’) during intrapartum care in line with national guidance.

3. The registered provider must implement an effective system for ensuring staff at Gloucestershire Royal Hospital interpret fetal monitoring traces accurately and escalate in line with Trust guidance to ensure all women and birthing people and their babies are cared for in a safe and effective manner in line with national guidance.

4. The registered provider must implement an effective system for ensuring staff at Gloucestershire Royal Hospital complete and escalate maternity early obstetric warning score (MEOWS) charts in line with national guidance during intrapartum and postnatal care.

5. The registered provider must implement an effective system for ensuring staff at Gloucestershire Royal Hospital complete venous thromboembolism (VTE) risk assessments.

6. The registered provider must implement an effective system for ensuring agency midwifery staff at Gloucestershire Royal Hospital have a comprehensive induction to the unit, are able to access the maternity electronic records system and Trust policies as well as enter and exit the unit without delay.

7. Within 21 days of this notice and monthly thereafter, the registered provider must provide a detailed action plan that includes the following:
a. A detailed plan of how it will ensure service users at Gloucestershire Royal Hospital have effective post-partum haemorrhage risk assessments and PPH proformas are used effectively to manage obstetric emergencies and reduce the severity of blood loss. The plan must identify how it will achieve this in the short to medium term, including any immediate actions taken.
b. A detailed plan of how it will ensure service users at Gloucestershire Royal Hospital have effective fetal monitoring in line with national guidance.
c. Summary report of the actions taken to address the immediate risk to service users at the Gloucestershire Royal Hospital, this should include detailed evidence of how you will achieve and monitor this.
d. The action plan must include assigned responsibilities, timelines for completion and measurable actions.

8. Within 21 days of this notice and monthly thereafter, the registered provider must provide to the CQC the following:
a. An updated action plan with clear details of progress on all conditions contained within this notice.
b. All reports written to provide assurance to the senior leadership team and/or Trust board to demonstrate compliance with the conditions.
c. The Trust maternity dashboard.

Treatment of disease, disorder or injury

Mr Kevin Luke McNamara is responsible for these services.

Assessment or medical treatment for persons detained under the Mental Health Act 1983

Mr Kevin Luke McNamara is responsible for these services.

Surgical procedures

Mr Kevin Luke McNamara is responsible for these services.

Diagnostic and screening procedures

Mr Kevin Luke McNamara is responsible for these services.