Monitoring questions for NHS trust level urgent and emergency care

Page last updated: 12 May 2022
Organisations we regulate

In the run-up to winter, it’s important that we understand the issues and challenges for trusts and how they are responding.

When our inspector calls you, they will focus on these specific key lines of enquiry (KLOEs). These will help them to understand the level of executive level support to the emergency department and patient flow through the hospital. You can open the questions to see the type of detail they will be interested in and use this to assess your own emergency department.


S1: How do systems, processes and practices keep people safe and safeguarded from abuse?
  • Has there been a structural review of the emergency department to understand how to ensure IPC and social distancing measures? (for example, isolation areas, aerosol generating procedures (AGP) areas, negative pressure rooms, areas for safe donning and doffing of PPE, signage)
  • Has the emergency department carried out a full capacity protocol assessment for all areas? If social distancing is likely to be compromised, does this link to the trust’s escalation plan?
S2: How are risks to people assessed, and their safety monitored and managed so they are supported to stay safe?
  • Have emergency department staffing models been developed for the next 12 months, and how is the trust supporting these?
  • If children attend the emergency department, is there a paediatric emergency consultant (PEM) and a minimum of two registered children’s nurses per shift? If not, what mitigating actions are being taken to ensure safe and effective care?


R2: Do services take account of the particular needs and choices of different people?
  • Has the trust supported any changes to the emergency department that specifically cater to the needs of children and young people, and those with mental health needs? Is there support to continue these changes where they have shown to improve the patient experience?
R3: Can people access care and treatment in a timely way?
  • How is the trust ensuring that issues relating to patient flow are consistently and rapidly escalated?
  • How are senior executives ensuring early involvement in flow issues?
  • How has the trust been involved in developing alternative pathways for patients with non-time critical presentations? These may be:
    • external to the trust - GPs, community health services, NHS 111, pharmacy, ambulance, urgent treatment centres, mental health services)
    • within the trust - urgent treatment centres, mental health services, speciality review - any patients under a specialty team that can avoid attending the ED, for example for post-op complications)
    • Have there been any initiatives with external partners (community services, health visitors, school nurses) to safely reduce demand for emergency care from children and young people?
    • Are there policies and strategies to enable early and dynamic discharge planning? What has the trust done to understand and remove delays in moving patients through pathways of care (examples may include Same Day Emergency Care (SDEC), speciality review, ward discharge teams, support services such as pharmacy, testing and transport).


W1: Is there leadership capacity and capability to deliver high-quality, sustainable care?
  • Do the trust’s leaders understand the challenges to quality and sustainability in the emergency care pathway during this period? Can they identify the actions needed to address them?
W3: Is there a culture of high-quality, sustainable care?
  • Has there been any impact on the culture of the trust in supporting the emergency department in response to the pandemic?
W4: Are there clear responsibilities, roles and systems of accountability to support good governance and management?
  • How is the board going to monitor progress against the escalation/winter plan?
  • Is the board assured that the trust’s escalation/winter plan is going to be effective?
W5: Are there clear and effective processes for managing risks, issues and performance?
  • How is the board kept aware of risks and issues in the emergency department, particularly related to seasonal demand, in a timely way?
W7: Are the people who use services, the public, staff and external partners engaged and involved to support high-quality sustainable services?
  • What role do the trust’s senior executives have on the A&E Delivery Board/Emergency Care Delivery Board? Has it continued to function during the pandemic? Has it signed off the local system level escalation/winter plan and is the board assured that the local system plan is going to be effective?
W8: Are there robust systems and processes for learning, continuous improvement and innovation?
  • Are there any examples of innovation and learning in the urgent and emergency care pathways in response to the crisis, that the trust wants to share?