Royal Sussex County Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

At our last assessment we rated this key question requires improvement. At this assessment the rating has gone down to inadequate. This meant people were not safe or protected from avoidable harm. The service was in breach of regulation 12 Safe Care and Treatment. We have asked the provider for an action plan in response to the concerns found at this assessment.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The evidence showed some shortfalls. The service did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Staff did not always report Incidents appropriately. Staff knew how to report incidents. However, staff told us that because no sustainable action or change happened after reporting incidents and raising patient safety concerns, they had stopped reporting all incidents that occurred.

Staff told us that risks escalated to senior leaders were not always understood in terms of their severity. Staff had escalated concerns about overcrowding and patient waits directly to departmental leaders. Although departmental leaders listened and tried to make improvements no sustainable improvement had occurred. Department leaders had developed a daily report sheet which recorded the unsafe practice and risk of each shift however no sustained changed to deal with the risks were identified.

Opportunities to learn from patient safety events were delayed as debriefs were not always undertaken promptly and potential learning opportunities missed. For example, staff told us about an incident of patient violence and aggression in the emergency department (ED) when staff were threatened. We did not find evidence of how learning from this incident was shared in the department.

Staff reported a total of 2,749 incidents across the Acute Floor Directorate. Of these, 6 incidents resulted in fatal harm and 5 caused severe long-term harm. Teams identified 59 cases of moderate harm, while 653 incidents led to low-level physical or psychological harm. In 2,026 incidents, staff confirmed that no harm was caused. Themes from reported incidents included overcrowding, corridor care, and delays in triage or treatment.

There was a process for learning from incidents to improve the service however it was unclear how learning from these meetings was shared and changes made because of them. The service held a monthly clinical governance meeting where reported incidents were discussed. Minutes from the meeting showed that themes included the impact of providing care and treatment in non-designated clinical areas. Staff told us they did not have time to attend these meetings or to read the minutes circulated after the meetings.

The department held weekly morbidity and mortality meetings with medical staff. Presentations from these meetings showed learning was taken from the incidents, however the sharing of the learning with staff in the wider department was not effective as staff did not have time to read the minutes of the meetings. A Morbidity and Mortality (M&M) meeting is a structured discussion focused on analysing adverse events, errors, and near misses in patient care, with the goal of learning from these events to improve future care and prevent recurrence. These meetings are crucial for promoting patient safety and quality improvement within healthcare settings

The department used the Patient Safety Incident Response Framework (PSIRF) and Local Learning Reviews (LLR) to respond and learn from incidents. PSIRF, is a mandatory framework within the NHS in England for how health services respond to and learn from patient safety incidents. We reviewed 3 Patient Safety Incident Investigations (PSIIs) reports and one Local Learning review and saw, on these occasions, they completed thorough investigations and shared the learning across the team. Families and those involved in the PSII were involved in the investigation and notified of the outcome. We saw that families had submitted their own questions to the investigation team, and these were answered in the final report. However, because staff told us they did not report all incidents we could not be assured the department leaders were fully aware of the patient safety incidents that had occurred and could not make improvements or change procedures to improve safety.

The evidence showed significant shortfalls. The service did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

Safety and continuity of care were not prioritised throughout patient journeys in the department. Patients experienced delays in receiving treatment and staff gave treatment in unsuitable areas of the department.

Staff did not manage or assess patient risk appropriately. For example, at the assessment we saw staff did not raise concerns about a patient who had very abnormal blood test results to the clinician in charge. The patient was situated in the temporary escalation space with no access to enhanced monitoring of their condition. This was unsafe as the patient was at risk of a cardiac arrest and should have been monitored closely in the resuscitation area of the department. At the time of the assessment there was no resuscitation bed available due to overcrowding in the department.

Patients attending the department, who did not arrive by ambulance, underwent a patient triage assessment where an advanced nurse called a Clinical Navigator directed them to the most suitable clinical pathway or department. Clinical navigators worked between 9.30am and 10.00pm seven days a week and improved the streaming of patients to the most appropriate area of the department because of their enhanced training. In the absence of a clinical navigator the senior triage nurse on duty performed this role.

Staff had difficulty tracking patients in the department accurately due to the extra number of patients cared for in the temporary escalation areas. Patients were meant to be tracked using trolley numbers and patient wristbands, but this did not always happen. For example, a patient with spinal fractures was triaged to the urgent treatment centre and then moved to the temporary escalation area of the major’s department. They were later found on a different trolley than recorded, after a 10-minute search. Staff said this was common due to patients being moved after investigations. The issue was worsened by patients not always wearing wristbands, raising serious concerns about tracking systems and communication with other departments, increasing the risk of poor clinical oversight in a busy environment.

Staff told us the computer system was not fit for purpose and most clinical information remained on paper. There were risks associated with using a mixture of paper and computer records. For example, when a patient was referred to a speciality or transferred, the speciality team used a different computer system which meant important patient information may not be communicated effectively.

During the assessment 11 patients had been in the emergency department for more than 24 hours waiting for a bed in the hospital. Staff told us patients often spent more than 36 hours in the department, and they were the ‘front door’ to the whole hospital. Staff told us that the flow of patients through the hospital would be improved if patients transferred to the hospital from other health care providers could be admitted directly to the ward that had accepted them.

During our assessment we met a patient who had sustained multiple rib and spine injuries after falling down their stairs at home. They waited on a trolley for 36 hours for admission onto a ward. This caused an increase in their pain and an increase in the risk of skin damage as they were cared for on a hard trolley with no pressure relieving equipment such as a pressure relieving mattress.

During our assessment we identified a patient with an infection and confusion, who had been waiting 22 hours for admission to the ward on a trolley. This caused further agitation and confusion to the patient as their symptoms were worsened by the loud sensory environment.

Patients arriving by ambulance also suffered significant waiting times. For example, a patient came by ambulance and was moved to a resuscitation bay. They were initially treated and then moved back to the temporary escalation area and stayed in the department for 23 hours and 49 minutes. Resuscitation bays are for patients who are very unwell. Patients were moved to the temporary escalation areas from the resuscitation area when condition had improved. However, there was a risk that they may deteriorate again in the temporary escalation areas without the staff being aware.

The service did not have effective systems and processes to ensure patients received the care and treatment they required. For example, a patient suffering a medical emergency was transferred from a neighbouring hospital and had to wait on a trolley for 33 hours for a bed to become available on a ward.

Staff told us patients were inappropriately placed in temporary escalation spaces which included the major’s temporary escalation areas, resus unit and waiting area. Safety and continuity of care was not prioritised throughout patient journeys in the department. Patients experienced delays in receiving the correct treatment. Staff gave complex treatment in unsuitable areas of the department.

Lack of flow in the department compromised patient safety. Poor flow meant that patients who needed to be admitted to wards could not be seen within acceptable time frames. Staff and managers escalated concerns to senior leaders. However, they did not always respond to the concerns. This led to poor patient experiences because people arriving in the department could not be treated promptly. Senior leaders did not appear to have a clear plan to redirect patient flow away from the emergency department to wider areas of the hospital.

There was a hospital wide Operational Pressures Escalation Levels (OPEL) escalation plan, staff used to raise concerns about safe care when the flow and pressure on the department was high and declare a critical incident if needed. The OPEL escalation plan is a system used by the NHS to manage and respond to increasing operational pressures in healthcare settings. OPEL 1 is defined as normal operating conditions, and the scale increases through to OPEL 4 which is the highest level of escalation. Staff told us that hospital managers had refused to declare OPEL 4 even when they felt the criteria had been met. This meant staff did not have confidence in the process for escalating concerns about patient flow.

Department leaders regularly reviewed patient tracking lists for medical specialities during the shift to assure themselves patients were in the most appropriate area of the department. Patient who needed care but not admission to the hospital were placed in one the Same Day Emergency Care (SDEC) units. Each SDEC had its own standard operating procedure (SOP) that was specific to a medical specialty in the department. The SOP contained the patient inclusion / exclusion criteria, the admission pathway and the physical layout of the area.

There were agreements with partnership organisations such as the local ambulance service to treat patients with specific conditions. For example, a paramedic could refer patients suffering from a respiratory illness directly to SDEC. The intention was to ensure patients could be seen more promptly. However, due to overcrowding within the department this process did not work effectively as there were more patients than beds available.

The department had allocated a quiet area within the department for patients with mental health needs. It had dimmed lighting and was quieter than the main areas. However, the area was not suitable for the length of time patients were there for. Patients would often wait here for several days before being well enough to go home or for a bed to become available in a mental health hospital. Staff observed patients with mental health needs and supported them while they waited to be assessed further. Although the environment was not always suitable for this; staff were proactive and emotionally supportive to patients and protected them from harm. There was a mental health liaison team provided by the local mental health trust. This team completed mental health needs and risk assessments and recorded these on their own notes system. Records showed these assessments were not always shared with the staff looking after patients in the mental health assessment area. This meant staff did not always have the information they needed to care safely for these patients. The acute floor completed annual ligature risk assessment as part of the trust wide ligature risk assessment program. Patients deemed at risk of self-harm underwent a risk assessment as part of their care plan.

Paper records were still in use. We reviewed 10 sets of patient records and found that they were not always completed to the required standard, for example pages were missing patient identification labels, entries were not signed and dated and assessments not fully completed. This meant staff did not have accurate records for the patient when assessing and planning treatment. Patient alerts were added to the electronic patient system and identified addition needs such as a learning difficulty however staff told us they often did not have time to check the electronic record and worked mainly from the paper records where these alerts were not always completed accurately.

Staff explained that although the department had adopted nationally recognised risk assessments to monitor patients during their stay, busy shifts often prevented them from completing these assessments on time or taking the necessary actions to ensure patient safety. These assessments included evaluations for falls, pressure area damage, nutrition, risk of deterioration, and sepsis screening.

During the assessment, we observed several handovers and board rounds, which were well-attended by the multidisciplinary team. Staff consistently shared relevant safety information and discussed key operational issues, including patient flow, staffing levels, and identified safety concerns. Actions were clearly allocated to appropriate team members to support the safe and timely progression of patients through their care pathways.

We requested audit data on compliance with the sepsis 6 care bundle within the department; however, the trust submitted data from across the organisation. It was not possible to extract data relevant to our assessment of the Emergency and Urgent Care department.

The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately.

The service had risk management policies, procedures and practices that aimed to minimise restrictions on people’s freedom, choice, and control. Mandatory training figures provided by the trust confirmed that between 94% and 100% of staff had received safeguarding training appropriate to their role.

Staff did not support all patients to help them understand their human rights in line with the Mental Capacity Act 2005 and the Equality Act 2010. Managers and staff assessed and monitored patients who came to the department in mental health distress. However, records showed that staff did not always consider completing the mental capacity assessment for some patients who showed they may lack capacity to decide about treatment.

Staff shared information about patients who had suffered harm or were at risk of harm with other agencies. Managers and leaders attended a trust-wide safeguarding committee every 3 months and had updates for adults, children, and specific specialisms. For example, in January 2025 topics covered included mental health and maternity.

Staff followed safeguarding adult policies when they identified abuse may have occurred. Policies referenced up to date national guidance. Leaders, managers and staff worked with system partners and had contracts with four Independent Domestic Abuse Advisors (IDVAs). The IDVAs provided day-to-day support to patients and staff around domestic abuse concerns.

Staff told us they reported suspected safeguarding issues as per the hospital policy. For example, staff had reported an allegation of sexual assault between two patients. We sought immediate assurance on this incident. However, during the assessment we saw male and female patients were still cared for near one another which affected privacy and dignity due to overcrowding of the department.

The Safeguarding Level 3 training, which included training on Deprivation of Liberty Safeguards (DoLS) and the Mental Capacity Act (MCA), data showed that 61 staff members were required to complete Safeguarding Adults Level 3 training, of which 42 had completed it, resulting in a compliance rate of 69%. For Safeguarding Children and Young People (CYP) Level 3, 318 staff were due to be trained, and 222 had completed the training, giving a compliance rate of 70%. Among staff groups, Nursing & Midwifery and Allied Health Professionals demonstrated the highest compliance, with 96% and 100% respectively for Adults L3. In contrast, the Medical & Dental group had the lowest compliance, with only 49% for Adults L3 and 58% for CYP L3. These figures reflected a need for targeted improvement, particularly within the Medical & Dental workforce.

The evidence showed significant shortfalls. The service did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff did not always inform people how to keep safe in the department. For example, staff provided some patients with portable oxygen cylinders, but we saw examples where staff rested the cylinders on patients’ legs without giving care advice about how to manage the cylinders because this may lead to medical device acquired pressure damage. There was also a risk that oxygen cylinders could fall on the floor which was creating a risk of fire or explosion.

The department took part in a trust wide internal assurance process called the “Weekly Safety Standards Assessment” which covered both patient care and the physical environment. In the most recent 3 audits, the department scored 70% in December 2024, 76% in January 2025, and 82% in February 2025. All scores were below the average score for the trust. Following our assessment, these scores have improved, and managers have used these audits as a key indicator to show improvement.

The trust leadership team reviewed senior department roles in nursing and job roles had been amended to ensure that there were senior nursing leaders in the department 5 days per week with a focus on quality and safety standards to improve.

Department leaders understood what was causing patient distress and escalated their concerns about patient risk to the executive team in relation to the poor performing areas of the department. However, there was no evidence this had improved safety or performance in urgent and emergency care.

The department used the National Early Warning Score 2 (NEWS2) tool to monitor patients at risk of deterioration. NEWS2 is a standardised scoring system used in the NHS to assess the clinical status of adult patients and identify those at risk of deterioration. We reviewed 10 sets of patient care records and found 6 had no NEWS2 recorded. This meant patients were at risk of deteriorating without the staff being aware.

Staff triaged patients to be seen in order of clinical need using a national clinical assessment tool. Patients with a higher acuity were reviewed first and prioritised within the department. When available, clinical navigators were involved in the triage process and directed patients to suitable areas of the department to reduce initial wait times.

Staff had access to the Safer Holding Policy, which incorporated current national guidance applicable to all staff groups. However, the trust did not submit training data following the assessment, so we were unable to confirm whether staff had received training in safer holding practices. Safe holding refers to the practice of gently and safely restraining a person to prevent harm to themselves or others. Records showed that 96% of eligible staff had received training in conflict resolution.

The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

People were not always cared for in a safe environment. On the morning of the assessment, there were over 30 patient trolleys in the temporary escalation area. Trolleys were close together and staff were concerned that they blocked access to emergency equipment when needed. Staff had developed a system called continuous flow. This was used to move patients from the temporary escalation areas to other places in the hospital such as wards or assessment units depending on their clinical need. This was not completely effective in addressing the issues with patient flow as when wards were full, they were cared for in ward corridors or patient lounges which were not always suitable or staffed.

The size, setting and design of the department did not align with best practice and legislation and did not meet the needs of the volume of patients attending the department every day. The bed capacity in the department was 46 cubicles and 5 urgent treatment cubicles in a separate building. Of the 46 cubicles, 5 cubicles were resuscitation trolleys, 25 were for majors and 12 were for patients with a mental health concern. There was also a cubicle set aside for 5 patients who were waiting to be reviewed by the medical team.

Waiting area seating across the department did not always meet the number of patients waiting in the department. Department leaders had installed further outdoor seating after a successful business case, but staff told us this still did not meet demand.

On the evening of the assessment, we saw patients in pain lying on the floor in the waiting area. There were 137 patients booked into the department and staff said this was normal. Patients were not comfortable, or offered pain relief, and they were not reviewed regularly during their wait. This created a risk for rapidly deteriorating patients because staff lacked oversight due to the high number of patients waiting to be seen.

Clinical staff described the resuscitation area as extremely small for a trauma centre and due to the size of the cubicles staff told us it was unsuitable for managing a major trauma or critically unwell patient. For example, staff had to manage a patient with uncontrolled bleeding in one of the cubicles and staff could not move safely around the cubicle due to the amount of equipment needed to manage the patient’s care needs.

Staff were unable to access and treat patients promptly due to overcrowding in the department. At times of overcrowding, the department admitted as many as 51 extra patients and most of these patients were placed in the major’s department in temporary escalation areas. This meant that space in the department became unsafe to meet the needs of patients. Staff had difficulty moving seriously ill patients in the temporary escalation areas which led to long waits and delays in receiving care. At the assessment we saw a patient who was on a trolley in the temporary escalation area choking on their vomit. Staff responded immediately but it took time to get the emergency equipment to the patient due to the number of patient trolleys in the way.

Fire exits were blocked by patients being cared for in the temporary escalation areas. Estates managers said department fire evacuation drills were unsuccessful as they could not get patients out of the department promptly. Senior nurses had been designated to act as fire wardens in the event of a fire. However, staff we spoke with expressed concerns about how the department could be safely evacuated if a fire occurred.

Leaders said the department was being rebuilt over a three-year refurbishment scheme. This consisted of an urgent treatment centre, a minor and majors’ area, a resuscitation area and a triage area. These areas would meet expected best practice and standards for trauma centres. Records showed the capacity of beds for the new building was proposed to be the same and would not increase the departments capacity. Leaders told us projects to re-direct patients to more suitable care areas such as Urgent Care Centres, Minor injuries or the GP would reduce the number of patients attending the department.

Staff were clear about their responsibilities about premises and equipment. They used equipment correctly and supported patients. However, they were not always able to monitor patients with equipment due to the volume of patients in the department.

Department managers completed safety rounds and audits took place in the department. Daily audits included temporary escalation areas and environmental risk assessments to prevent significant self-harm. Weekly audits included minimum safety standards and Infection, Prevention, and Control (IPC) assurance. Monthly audits included fire safety, medicine safety, mental health care and hand hygiene. Compliance with temporary escalation areas audits were low with a completion of 31% in January and February 2025. However, this had improved to 100% in March and leaders said there were plans to improve compliance through a daily review completed by managers.

The mass casualty plan was in development and a draft evacuation plan was in place.

The evidence showed significant shortfalls. The service did not make sure there were enough qualified, skilled and experienced staff. Managers did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

Staffing levels were not safe because the planned versus actual staffing levels did not ensure patients received consistently safe, quality care that met their needs. Medical staff told us there were not enough staff to cover the department. The department had 24-hour consultant cover. Two consultants were allocated during the day shift, and 1 consultant was allocated during the night. Medical staff told us this had a significant impact on patient care as the total number of resident doctors did not meet the capacity of patients in the department. Resident doctors followed shift patterns that gave the service 2 in the morning, 4 in the afternoon, 2 in the evening, and 1 overnight. Records showed staffing allocations were rarely met, with a staff member saying they have 2 resident doctors 10% of the time which made it extremely challenging to manage the department.

Consultants told us there was a significant gap of medical staff particularly consultant, middle grade and GP roles for the urgent care centre. There was a clear message from the consultant body that the impact of the depleted numbers of doctors had led to them providing unsafe care to patients. They felt unsupported by the senior leadership team in the trust and that their voice did not count, this seriously impacted their mental and physical health.

Nurse managers used a staffing acuity tool to assess nursing staff levels. However, the tool did not consider patients cared for in temporary escalation areas of the department. Nursing staff raised concerns because the gap in staffing posed a significant risk and was unsafe as there could be up to 30 more patients than they had been staffed for at times in the department. Staff said their normal ratio of patients was 1:6. However, during times of overcrowding this worsened to 1:10. On the day of the assessment the number of nursing staff were adequate for the department before patients were placed in the temporary escalation areas. However, as the temporary escalation areas filled up with patients no more nurses were available to look after these patients. This meant the nurses on duty were responsible for more patients than was safely planned for.

Department managers used a capacity and demand staffing tool to plan their medical and nursing staffing in combination with heat maps. A heat map is a visual aide to show when high and low levels of patients attend the department. Heat maps found that Monday and Tuesday afternoons were the busiest time for the department. Their analysis using this tool also uncovered surpluses in staffing provision during the nighttime shifts. Leaders used this information to consider different staffing rotas. For example, because of the staffing mapping exercise managers added additional consultants on Monday and Tuesday to prioritise the major’s area. However, there was no evidence that managers increased nursing numbers on these days.

Department managers staffed an area of 12 cubicles for patients attending with mental health needs awaiting assessment. Nursing staff were rostered to the area and a registered mental health nurse (RMN) supported staff when demand was high. RMNs were agency staff and were not employed by the trust. This is because registered nurses do not have a mental health qualification.

Flow coordinators had been employed to complete administrative tasks to support the flow of patients. Tasks included booking transport, answering telephone calls and signposting visitors and staff who were not familiar with the layout of the department. They also monitored the timeliness of requested patient tests and ensure they were completed as soon as possible.

Leaders supported staff to keep their professional practice and knowledge updated. Managers took into consideration skill development and staff aspirations. Staff providing 1-to-1 support for patients had the knowledge, skills and experience to do so.

Medical staff had access to suitable emergency simulation training every two weeks. Training included 22 sessions accommodating 10-12 participants for each session. Three medical consultants had protected time in their role to complete medical training for resident grade medical staff. The General Medical Council staff survey in 2024 reported high satisfaction scores with clinical supervision (93.61%) and the induction process (79.31%) for the department however, satisfaction with workload was low at 41.9%.

Recruitment, disciplinary and capability processes, and ongoing checks were safe, fair, and reviewed to ensure there was no disadvantage based on any specific protected characteristic in line with the Equality Act (2010). Recruitment policies required diverse interview panels to promote fair decision-making and avoid unconscious bias. Leaders made reasonable adjustments for disabled candidates including a guaranteed interview. Managers followed the ‘Workforce Race and Disability Equality’ Standards as part of their analysis of applications for roles.

The recruitment process ensured all staff, including agency staff, were suitably experienced, competent and able to carry out their role. Managers used interview templates to provide objective and equal evaluation to ensure candidates met the essential criteria for the role as part of the interview process.

At the time of the assessment there was a trial of a new shift pattern for GP's within the Urgent Treatment Centre (UTC). GPs told us there was potential for more patients to be seen and treated in the UTC and trialling a new shift pattern could support the flow of patients within the whole department when there was overcrowding.

Records showed that staff had received the required mandatory training to work in a clinical setting. Attendance was above 95% in all areas apart from adult basic life support which was 78%. Staff who had not yet been updated in adult basic life support had a date to attended within four months of the assessment.

At the time of the assessment nursing staff sickness rates in the emergency department were low at 4.19% and medical staff sickness rates were even lower at 0.44%. Staff turnover rates at the trust were 8.4% at the time of the assessment which was better than expected.

The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The service did not effectively assess or manage the risk of infection during busy periods when they cared for patients in temporary escalation areas to increase capacity. Staff put patients at risk of hospital acquired and contagious infections because they placed trolleys too close together when capacity was high. During the assessment we saw patients with suspected contagious infections not isolated from other patients due to lack of space.

Not all staff washed or sanitised their hands in between patient contact. Managers completed an infection prevention and control (IPC) audit in October 2024 which showed poor staff compliance of 31%. Data for hand hygiene audits in the last 12 months was variable. In November 2024, compliance was at 41% which improved to 90% by February 2025. Data for commode cleanliness was poor between August 2024 and January 2025 with compliance ranging between 55% and 75%. However, this improved to 100% in February 2025. We saw an action plan was in place to drive improvements in IPC, but consistency was a challenge due to the overcrowding in the department.

The department had personal protective equipment (PPE) such as gloves and aprons available which met recommended national guidance. Staff used PPE correctly most of the time however, we did see examples where staff were wearing gloves away from designated bays where there was an infection risk. There were multiple antibacterial hand gel dispensers in the department but many of these were empty so staff could not sanitise their hands easily. Although there was an audit system in place to check levels of PPE available for staff on the day of the assessment, we saw some glove dispensers were empty. We also saw unsecured sharps clinical waste bins had been left open and unattended which was an infection risk to anyone who could access them. Staff cleaned trolleys in between patient use, but it was not possible to clean the floor due to the overcrowding in the department.

The service had clear roles, responsibilities and procedures around infection prevention and control that met current and relevant national guidance. Department managers provided a clinical nurse specialist to support the department to improve hand hygiene and environmental IPC. The IPC team conducted daily support visits to the department to deal with questions and promote good practice. Department managers used newsletters to promote better practice by staff. Staff received IPC training and understood their role and responsibilities for maintaining high standards of cleanliness and hygiene in the premises and their own personal hygiene. Records showed that 100% of eligible staff had attended infection prevention and control training in the 12 months before the assessment. The overcrowding and high patient attendance meant staff did not aways practice high quality infection prevention and control measures.

The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Staff did not always store medicines safely and securely. Recent audits reported broken cupboards and locks. Staff did not always follow the trust ‘controlled medicines’ stationery guidance. Therefore, there was a risk that a loss of controlled stationery such as prescription pads would not be noticed by staff.

Pharmacy supplied ‘over labelled’ medicines in the emergency department (ED) which included discharge prescriptions. Over-labelled medications are pre-packs of commonly used drugs, typically supplied by a hospital pharmacy, that have a pre-printed label containing dosage instructions and other information. Healthcare staff then manually add the patient's name and date to these labels, making them suitable for direct use by patients. However, the quality of the over labelling of the medicines in the To Take Out (TTO) cupboard was variable. This posed a risk that discharge patients may receive medicines with incomplete labelling and directions for use.

We were not assured that medicines were prescribed or administered consistently on time. Incident and audit data provided by the trust included examples of insulin not being prescribed within safe time frames and there were delays in obtaining intravenous (IV) access and administering IV antibiotics and IV fluids as recommended within the sepsis pathway. Also, staff told us that patients receiving "temporary escalation areas care" were at increased risk of not receiving their medicines on time. Staff said the department was not structured to complete routine medicine rounds.

Pharmacy services were available from 7:30am to 8.00pm, seven days a week by a team of 3 pharmacists. One pharmacist described how they prioritised the identification and medicines reconciliation for patients who take time critical medicines when at home, to support the prescribing of these and other medicines for these high-risk patients. Following a patient risk model, they completed medicines reconciliation for patients within the emergency department. Medication reconciliation is the process of comparing a patient's medication orders to all the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions.

Medicines reconciliation rates and anti-microbial spot audit data were not available for the department. Staff told us that the lack of an electronic prescribing and administration (ePMA) system within the department made the data collection too time consuming. This meant there was an increased risk of medication errors, missed or delayed treatment or a missed opportunity to improve the service