St Mary's 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

This means we looked for evidence that people were protected from abuse and avoidable harm.

We assessed 8 quality statements. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

We found concerns around training compliance, limited staff knowledge in safeguarding and staffing pressures affecting patient flow during the winter period. In addition, we identified high‑risk environmental issues in one ward.

However, we saw evidence that people were protected from abuse and avoidable harm and there was a positive learning safety culture where staff were open and honest when things went wrong or could be a risk.

The service was in breach of legal regulation in relation to safeguarding.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events.

The service fostered a positive culture of safety based on openness and honesty. Staff logged incidents in line with the trust’s electronic reporting system, and leaders shared feedback about incidents through daily huddles, meetings, newsletters and emails. Staff we spoke with were able to confidently describe recent incidents and explain the action taken in response to reduce the risk of recurrence. Monthly governance reports were also displayed on ward quality boards, which helped staff remain aware of incidents, themes and learning within their area. Governance insight newsletters also highlighted key learning, improvement priorities updates such as Martha's Rule and examples of good practice. Staff handovers included information about incidents from the previous shift, which further supported shared learning and continuity. Staff held a daily 30-minute end of day handovers and huddles in the chemotherapy unit, which leaders confirmed supported communication and oversight.

The service had clear processes in place for reporting, investigating and learning from incidents using the Patient Safety Incident Response framework (PSIRF). PSIRF is an NHS approach in England that explains how organisations should respond when something goes wrong in patient care. The trust had embedded PSIRF for five years, having been an early national pilot site, placing the organisation ahead of national implementation and reflecting a high level of maturity in safety systems and culture. The trust also contributed to system wide learning regionally through delivery of webinars, participation in national forums and support for education in safety science and capability building. Working within a group model in partnership with another trust, the service enabled the consistent spread of learning across organisational boundaries, including collaborative working between patient safety teams and shared learning from incidents.

The service utilised after-action reviews, thematic reviews and swarm huddles to support learning and improvement. For example, we saw evidence of a pharmacy safety event involving the mislabelling of medication which was investigated through a swarm huddle. We saw that the huddle used the Systems Engineering Initiative for Patient Safety (SEIPS) framework and led to immediate safety actions and five improvement ideas.

The service also held a weekly pre-meet before the PSIRF meeting to identify qualifying incidents, look at themes and trends and agree the most appropriate response. The patient safety specialist then monitored themes through the monthly patient safety report.

A dedicated Prevention of Avoidable Harm Shared Governance Council reviewed ward-level data on falls, pressure ulcers, deteriorating patients, and nutrition and hydration, to promote shared learning across wards and departments. Staff told us this approach had helped to reduce pressure injuries and falls in some areas.

The majority of incidents were low or no harm, similar to the trust overall, and no trends were identified in more serious incidents.

Incident data from August 2025 to January 2026 reflected an open reporting culture and was used to inform learning and improvement. Staff investigated incidents, identified themes and implemented actions to reduce risk. For example, of the 182 falls reported across medical wards, 148 caused no harm and the rest caused low harm. The trust reported a 23% reduction in falls had been achieved at the time of assessment as a result of improvement work in this area. Learning from these incidents helped the service develop targeted actions to prevent future falls. Pressure ulcers were also reviewed to improve preventative care. Also, the service reported no never events during this period.

Leaders confirmed that none of the trust’s Patient Safety Incident Investigations (PSIIs) in the past year had related to medical care specifically, instead, incidents were said to be managed through PSIRF using after action reviews. We requested examples of after-action reviews in the past year during the assessment, but none were provided to us.

We scored the service as 2. The evidence showed some shortfalls. The service faced patient flow challenges. Although some safe systems of care were maintained, ongoing discharge issues from the wards prolonged patient stays.

The trust had a full capacity policy outlining the processes to be used when the hospital reached full capacity. However, the policy was past its review date (due December 2024). Leaders told us the update had been intentionally paused while the hospital implemented continuous flow and the Your Next Patient process, as these programmes were expected to change escalation and operational responses. In the interim, staff continued to use operational escalation arrangements, including site meetings, bed meetings and senior oversight to manage capacity and flow pressures. However, because the full capacity policy had not yet been updated to reflect the new continuous flow and Your Next Patient arrangements, there was a risk that staff did not have one current, agreed document setting out the trust’s full capacity response.

Delays in discharge and patient flow were attributable in part to system wide capacity constraints, including pressures from packages of care, mental health input availability and community capacity. The trust was actively engaged in a system-level improvement work at the time of the inspection, participating in discharge improvement programmes and partnership working with system partners to address flow pressures across the island.

Patient flow was not consistently effective because medically optimised patients were not always discharged in a timely way, and the same day emergency care (SDEC) pathway did not always support timely onward movement of patients. This meant some patients waited longer than necessary for admission, review or discharge which affected bed availability across the hospital.

Most medical patients admitted through the emergency department (ED) did not have an inpatient bed allocated in a timely manner, and the hospital escalated from Operational Pressures Escalation Level (OPEL) 3 to 4 during the assessment. Staff told us that delayed discharges were a significant contributor to flow pressures because beds remained occupied by patients who no longer had a medical reason to stay in hospital.

Delays in patient discharges were evident on the wards we visited. On one ward, 27 patients were observed, 10 were medically optimised for discharge and awaiting packages of care and mental health input. On another ward, we observed 5 medically fit patients who were awaiting packages of care before being discharged. Staff consistently identified discharge issues as the wards biggest concerns affecting patient flow.

The main causes of delayed discharge were packages of care, mental health input and equipment needed to support safe discharge. Staff reported that mental health referrals had become more difficult since recent service change, with reduced involvement and support from the mental health team and that slowed down discharges as a result. Staff also told us that equipment delivery, for example, items needed to support a safe discharge home, could take up to two days from referral, although the service did meet the required timeframe when escalation criteria was activated. These delays meant that patients who were medically fit remained in hospital, reducing the availability of beds for patients waiting in urgent and emergency care areas.

The hospital had systems to identify patients ready for discharge, but these systems were not always effective in resolving delays quickly enough. Discharge coordinators supported safe transitions and collaborated with social workers and the local authority to facilitate discharge where needed. We saw that patients who were likely to need support on discharge, were flagged early to discharge coordinators, enabling arrangements to be made in advance. We observed that patients identified as having no medical reason to remain in hospital were reported daily, with senior staff escalating to identify solutions. Despite these processes we still found patients who were medically fit for discharge waiting in hospital for packages of care, equipment or mental health input.

The Transfer of Care team (TOC) supported discharge planning and ward staff told us the referral diagram to access the team was easy to follow. We saw that the referrals must be made at least 48 hours before the patient’s estimated discharge and it applied the national eligibility criteria based on the Care Act 2014 to assess the individual needs of each patient.

However, some ward staff reported that meeting the 48-hour requirement was challenging due to changes in patient acuity, delays in clinical decision making and administrative issues.

Leaders told us reinforcing retraining regarding TOC team referrals had been put in place, which had led to recent improvements in referrals to the discharge lounge. Junior staff education had raised awareness of the benefits of earlier and effective discharge lounge referrals to meet their cut-off time of 8pm. We spoke to staff at discharge lounge and they agreed with this.

The trust tried to reduce delays by using its usual processes and working with partners. This suggests the problem was partly due to wider system pressures, not just issues within the trust itself. At the time of inspection, the trust was already working to improve things through the Discharge Assessment group and other system-wide programmes

The hospital had a discharge lounge for patients who were medically fit for discharge and were experiencing delays. For example, delays in setting up care packages for people when they returned home. To ensure the safety of patients, there was a clear set of inclusion / exclusion criteria for the discharge lounge.

However, staff reported that the discharge lounge was located too far from the main hospital, making patient transfers more difficult. The trust advised that the location was a deliberate design decision to support timely access to patient transport and facilitate discharge flow.

The same day emergency care (SDEC) unit did not always support effective flow after it closed at 8pm. Staff described challenges moving patients through stages after closure, with some patients remaining in chairs for prolonged periods awaiting review or onward movement. Staff also reported that patients under the care of the twilight or medical team could remain in the unit for prolonged periods. SDEC staff described their activity as heavily shaped by pressures in the emergency department and acute assessment unit, with a noticeable increase in the winter season.

A notable improvement since the last assessment is that the Chemotherapy Unit now had a 24-hour patient helpline, pre-treatment education and orientation that linked patients to the acute oncology team. Although there was no onsite oncologist, the unit received weekly visiting consultant support from 2 nearby trust hospitals. Those consultants could access online prescribing remotely, allowing patients leaving the unit to receive medication to take home to continue their treatment cycle.

The trust had established a structured approach to oversight in their meetings. These included a late evening operation escalation meeting, brought together with the clinical site manager, ambulance representatives, the senior manager on call and the executive on call. An afternoon daily site meeting aligned all clinical areas including emergency department, wards and day surgery units on capacity and flow performance. The service also held daily bed meetings to identify patients ready for discharge and agree appropriate arrangements for them.

We scored the service as 1. The evidence showed significant shortfalls. The gaps in training, knowledge, and consistency outweighed the service’s operational strength. However, the service concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Staff did not have up to date knowledge about safeguarding. Safeguarding training compliance was below the 90% trust target across several key areas. Safeguarding Adults Level 3 compliance was 39% (52 of 643 staff), with particularly low rates for medical and dental (23%), allied health professionals (43%) and nursing and midwifery (56%). Safeguarding children Level 3 compliance was 81%, with medical and dental at 54%. Overall doctor compliance with safeguarding training was 77.6%. This issue was evident during the assessment, where we found that 5 out of the 6 staff members we asked, were unable to describe the trust’s process for responding to a disclosed safeguarding concern. This created a risk that staff may not consistently recognise, escalate or respond to safeguarding concerns in line with the trusts safeguarding processes and delay appropriate action to protect patients from avoidable harm, particularly where concerns were not clearly disclosed.

However, data provided by the trust indicated a 9.3 % increase in internal safeguarding referrals compared to the previous financial year, suggesting improved staff awareness and recognition of risk. Section 42 enquiries initiated by the local authority reduced by 53% compared to the previous year, suggesting more effective early intervention and strengthened safeguarding processes at the time of the inspection. None of the Section 42 enquiries related to failing in direct 1 to 1 care.

Information sharing was inconsistent. Leaders told us safeguarding concerns were discussed during huddles to inform staff of referrals made. However, some staff were unable to clearly explain recent learning from safeguarding incidents. Leaders also acknowledged they were not always assured that 1 to 1 care for patients could be provided when needed, citing difficulty sourcing enhanced observation due to workforce limitation.

Leaders were open about compliance being below expected standards. They described a trust-wide training needs analysis across more than 5000 roles to review whether the right staff had been assigned the right level of training and plan to move from a three-year cycle to updated and more frequent safeguarding training that incorporated learning from reviews and incidents. Leaders explicitly recognised that training should support competence and not just compliance.

Safeguarding policies for adults and children were available on the trust’s intranet to help staff recognise and report abuse and neglect. Leaders described a multidisciplinary safeguarding team that covered allied health professionals, social workers and staff with emergency response experience. The safeguarding team conducted regular ward walkarounds to identify concerns and offered ward sisters monthly safeguarding supervision with a more experienced practitioner. The team operated a clear “one door” process for Section 42 enquiries (under the Care Act 2014, which requires local authorities to investigate suspected abuse or neglect of adults at risk) routing concerns through the safeguarding team with liaison back to the local authority. The team described the ‘one door’ approach as using a single point of access to receive, coordinate, and manage all referrals and requests

Leaders said they could quickly access records and used ward-based reviews to help make decisions when safeguarding concerns were unclear. The safeguarding team confirmed that to reduce harm when safe staffing levels could not be achieved, mitigations included bay observation, shift management and break planning. Leaders identified Colwell and Whippingham wards as having higher safeguarding activity due to patient cohort needs (delirium acuity and dependency) and described targeted supporters comprising of senior staffing in those areas.

Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) arrangements were well managed in the areas inspected. In particular, on Whippingham and the stroke ward, appropriate incident reports had been completed regarding safeguarding concerns, for example in response to incidents of physical aggression.

Staff demonstrated strong professional curiosity throughout the hospital, consistently challenging visitors on the wards during the assessment to confirm their identity and reason for presence.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The trust was implementing Martha's Rule through Call for Concern process, which allowed patients, families and carers to ask for an urgent clinical review if they were worried about a patient's condition or felt their concerns were not being heard. During the assessment, the Patient Wellness Question assessment had been established on 6 wards and the hospital’s Marthas Rule lead was progressing implementation across the remaining wards ahead of the national March 2027 deadline.

Staff understood how to escalate concerns about deteriorating patients and used risk assessments to keep patients safe. Leaders and staff could describe the risk assessments they used to identify and monitor patients whose condition may deteriorate. We reviewed 14 patient records and observed the outreach team actively sought out patients whose risks were increasing. Staff knew how to escalate concerns and monitor deteriorating patients.

Patients who required enhanced supervision from security staff received this support from trained staff who understood their role. During the assessment, we observed patients receiving 1 to 1 or 2 to 1 supervision from trained third-party security staff due to acute confusion or expressing distress/agitation. Security staff providing this support had received appropriate training, were briefed on the individual patients they supervised and understood the reason for their presence. We spoke to 2 security staff, and they were both trained in restraint and understood that the reasons for their presence. On Colwell ward we observed a calm and respectful approach by all staff members with a patient with confusion who had left the bay.

The service actively involved families in risk management. On 4 wards, we observed relatives signing into the wards and attending mealtimes, which was routinely encouraged practice to support patients. Patient feedback reinforced the safety culture. A patient on a respiratory ward said they felt safe that call bells were “always answered”. Another patient said they felt safer in hospital than at home, particularly when their breathing changed or worsened.

National Early Warning Score 2 (NEWS2) is a clinical tool used in the NHS to identify patients who may be becoming seriously unwell. Trust-wide, NEWS2 compliance was above the trust target of 80%. During the assessment, we reviewed 14 sets of notes. We saw risk assessments for VTE, pressure ulcers and falls were regularly completed. However, inconsistencies were identified between written and electronic VTE documentation.

We reviewed data from August 2025 to January 2026, which highlighted falls as a significant and recurring issue across medical wards. Compton ward was used as a step-down, ward to manage winter pressures, and had recorded the second highest number of falls, with 44 out of 182 falls during that period. Staff identified that increased patient mobilisation on this ward was driving rising fall risk.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control environmental risks to maintain a consistently safe setting.

Storerooms were clean, tidy and well ordered. Oxygen was stored securely and with full cylinders available. Nitrous oxide was in date and correctly stored off the floor and consumables were checked in date and recorded against expected equipment and numbers. Most wards also had secure entrances and exits with good visibility from the nurses’ stations, supporting oversight of patients and visitors.

However, we identified some environmental concerns. Staff expressed concerns about the ward layout on the stroke ward and said close oversight was required to keep patients safe. A reconfigured bay layout was specifically identified as a safety concern. Data from August 2025 to January 2026, showed that the stroke ward recorded the highest number of falls, recording 49 out of 182 hospital falls during that period. A falls deep-dive analysis identified that certain bays carried higher risk because of the ward’s infrastructure. Staff told us that patients in those bays had other medical needs beyond stroke care. The trust acknowledged these concerns and provided evidence that falls were concentrated in bays less visible from the main ward base. Mitigations including enhanced observation and cohorting of higher acuity patients were in place, though work to fully embed this arrangement was ongoing at the time of the assessment.

The service had introduced Your Next Patient (YNP) spaces to support patient flow when capacity was under pressure. On two wards, we observed 2 patients using a YNP spaces. Patients were observed seated in chairs around a clutter free area that was suitable for their immediate needs.

Equipment availability and maintenance were generally well managed. Staff reported having access to sufficient equipment including resuscitation trollies and hoists. Staff could describe how to order specialist equipment such as pressure relieving mattresses and there was a clear process for reporting faulty equipment. Resuscitation trolleys were tamper-proof, clean and subject to daily and weekly checks with records confirming compliance. Ligature cutters were available on the wards and staff knew where to find them.

The service provided evidence that mandatory fire safety training compliance was 90% for most staff groups; however, compliance for medical and dental, was significantly lower at 66%. We found fire extinguishers were in date and routinely tested and staff had access to fire risk assessments.

The service was carried out in accordance with the Control of Substances Hazardous to Health Regulations 2002 (COSHH), ensuring that all hazardous substances were correctly identified, handled, and controlled in most of the ward areas we visited.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support and supervision.

The service did not always maintain safe and effective staffing levels consistent with patient acuity and dependency, and the evidence demonstrated recurring pressures on the pharmacy, nursing and medical workforce. This volume and pattern of the data provided indicated that staffing risk was a persistent operational issue.

Hospital data showed that between June 2025 and February 2026, 121 incidents were logged by staff relating to staffing levels, citing vacancies, workload pressures, short notice absence, no bank staff availability and long-term sickness. Several ward level examples reflected the operational impact.

The service did not always have enough nursing and medical staff to provide consistent cover across all clinical areas. During our assessment, leaders told us that 3 wards were short staffed. On one ward staffing was 1 registered nurse and 1 healthcare assistant (HCA) short of required levels. We also observed daytime 1 to 1 patient care shifts could not always be filled. Staff told us this made it more difficult to support distressed patients safely and consistently.

Patients also described the impact of staffing pressures. Patients on Appley ward told us staffing support could be “patchy”, particularly when patients needed help with personal care. This meant there was a risk that patients did not always receive timely support with their care needs.

Medical staffing did not always support consistent clinical cover. In the coronary care unit (CCU), staff told us that rotating between the monitored and step-down areas meant clinical cover was not always consistently present. Although staff said the 7 patients in the step- down area had been assessed as suitable for step-down care and did not require continuous monitoring, reduced medical cover on some days created a risk that review, escalation or decision-making could be delayed. Staff reported that medical staffing was adequate on the day of the visit. However, concerns were raised regarding the consistency of future medical cover.

Staff worked flexibly to maintain patient safety, but this did not fully mitigate the impact of staffing gaps. On the second day of the onsite assessment, senior leaders informed us that the stroke ward was also short staffed. While staff stated they would prioritise and adjust between themselves to maintain patient safety, they acknowledged that limited medical shifts contributed to inconsistency in cover. Staff on Whippingham ward also supported this view and said they experienced challenges because of the constant changes of medical staff.

Leaders had systems to identify unsafe staffing levels, but these were not used consistently. Leaders described Red Flag Reporting (a mechanism from NICE Safe Staffing Guidance for registered nurses requiring staff to report when staffing falls below safe levels). However, they acknowledged this process was not used consistently. This limited leaders’ assurance that staffing risks were always identified escalated and responded to promptly.

The trust had established governance processes to support safer staffing, including evidence-based establishment setting through the Safer Nursing Care Tool, acuity and dependency reviews, and triangulation of workforce data with professional judgment. The Nursing Annual Safer Staffing Report 2025/26, presented to the People Committee in April 2026, demonstrated structured oversight of nursing establishments across the groups. However, these governance arrangements did not fully mitigate the operational staffing pressures identified during the assessment.

Workforce vacancies and turnover created ongoing pressure on staffing and leadership capacity. The hospital had a longstanding consultant and senior medical vacancies and continued to rely on temporary staff. Turnover for medical and dental staff grades was 12.2% in January 2026, with medical and dental training posts at 9.9% and consultants lower but rising. Leaders reported longstanding consultant and senior medical vacancies. Leaders described creative workforce solutions, such as Certificate of Eligibility for Specialist Registration (CESR) pathways, but said reliance on temporary staff continued, and smaller specialty teams were at risk of leadership gaps.

Senior nursing leadership was not substantively in place at the time of the assessment. The nurse director post was vacant at the time of the assessment, and interim cover was provided by the deputy chief nurse, who was present for 3 days per week on the island and was contactable on other days while recruitment was underway.

Appraisals rates were below expected trust targets in several groups. Data showed that for staff in the medicine and diagnostics division, overall appraisal compliance was at 82.3%, allied health professionals were at 80.6%, and estates and ancillary staff much lower, at 58.2%.

The Chemotherapy Unit had no vacancies, although a capacity and demand audit identified it was 2 Whole Time Equivalent (WTE) short. Staff and leaders acknowledged the pressure of being the only cancer team on the island and were exploring retention incentives.

Whippingham ward demonstrated that it had no shortfalls in nursing staff and so was fully established. The ward usually had 4 doctors present on each shift, which sometimes reduced to 2 when support was needed elsewhere in the hospital.

Leaders demonstrated strong insight into the recruitment challenges across the wards, which were linked to the geography of the island, size of the hospital and sub-specialisation of its trainees. There was successful progression of overseas doctors into substantive senior roles and the service trained many of its own nurses through apprenticeships and internal development routes. Education investment was described as aligned to service needs and leaders who are actively exploring rotational models and cross site support where specialist teams were small.

The Trust had established a Frailty Consultant Practitioner role at the time of the assessment, providing specialist clinical leadership, supporting patient flow, and enhancing care for patients presenting with frailty. This presented a positive addition to the clinical workforce model in this area.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service assessed and managed the risk of infection effectively. Leaders detected and controlled the risk of infection spreading and shared concerns with appropriate agencies promptly in line with national guidance.

Most areas of the service inspected were visibly clean and free from clutter. Cleaning records were up to date and demonstrated that all areas were cleaned regularly, with “I am clean” stickers placed on equipment to confirm. Domestic staff were assigned to each ward and could describe cleaning products and methods clearly and demonstrated extensive knowledge of Infection Prevention and Control (IPC) practice.

Staff followed “bare below the elbow” guidance and adhered to IPC precautions throughout the assessment, which included hand washing, use of hand sanitiser on entry and exit of clinical spaces and wearing personal protective equipment (PPE) when required. Chemotherapy specialist sharps bins were in use and handled properly and effectively as required under the Control of Substances Hazardous to Health (COSHH) Regulations 2002 and the Health and Safety at Work etc. Act 1974. Hand hygiene facilities met national standards. There were sufficient hand-washing sinks available, with soap, disposable hand towels and hand decontamination instructions displayed above each sink.

IPC signage on doors to specific areas and side rooms supported appropriate entry behaviours for patients, visitors and staff. The service operated a 2-stage audit process for hand hygiene and PPE with areas undertaking self-audit supplemented by peer audits.

Patient feedback reinforced the IPC culture. Patients on Appley ward described the ward as “very clean”. Another patient on Whippingham ward said commodes and chairs were cleaned after use and confirmed bedlinen was changed whenever needed.

However, Compton ward had only 3 side rooms available for isolation, which had presented challenges during a recent flu and norovirus outbreak. Staff described the ward as having poor side room capacity, meaning they quickly became unavailable for use when patients with IPC concerns needed them for isolation. Staff did however describe the incident as well managed overall, and no onward harm was reported.

We scored the service as 2. 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.

The service worked with patients and partners to make the best use of medicines, using well-developed digital systems that demonstrated that learning from previous assessment findings had been implemented. At the time of this assessment, most ward-based medicines were correctly labelled with reduced expiry dates following opening, and records relating to the return of controlled drugs (CDs) had been fully completed.

Staff told us there was an established process for monitoring clinic room temperatures in the Acute Assessment Unit (AAU) with an upper limit of 25°C. However, we did not observe consistent documented escalation when temperatures exceeded this limit. The hospital's policy on temperature monitoring and clinic rooms where medicines are stored states that “medicine storage areas must have an ambient room temperature range of 15°C to 25°C for most medicines, although some can be stored up to 30°C”. We saw instances where medication required storage at 25°C, although recorded ambient temperatures exceeded this limit and there was no evidence of documented actions. Leaders and managers told us there was currently no electronic system for temperature monitoring or automated alerts. However, updating the Standard Operating Procedure (SOP) to formalise responsibilities and escalation process is underway. The AAU’s monthly Department Medicines, Storage and Security audit had reported 100% compliance for the past six months, including January 2026, when room temperatures were recorded above the 25°C limit.

The chemotherapy unit demonstrated controls around systemic anti-cancer therapy (SACT). Consultants used an e-prescribing system to prescribe SACT remotely. Staff reported the system as responsive and well supported. We observed patient identification and allergy status confirmation prior to treatment and interventions. Patient experience of medicines was positive. Patients had To Take Out (TTO) supplies arranged for continuing cycle medicines. SACT passports were in active use, although staff acknowledged these could sometimes take a while to issue. Pretreatment patient education was in place. A patient on Appley ward told us their medicines were given on time and that when medicines were changed, staff provided written information explaining the changes.

A dedicated pharmacist worked in AAU and prioritised patients TTOs using an electronic system. The key performance indicator (KPI) for TTO turnaround was 180 minutes. Prescription tracking system data showed the service was meeting this target on average, with turnaround improving from 122 minutes in November 2025 to 114 minutes in February 2026 and the proportion of prescriptions completed within 150 minutes rising from 71% to 73% across the same period.

Weekly multidisciplinary meetings were held which staff reported had reduced medicines related errors. Medicines reconciliation took place in both the Emergency department and Acute Assessment Unit. Medicines reconciliation is checking that a person’s medicines are accurate and up to date when their care changes. The same day emergency care (SDEC) unit had an outreach service that could take bloods or administer medications and provide support to patients following their discharge, with International Normalised Ratio (INR) checks carried out a few days after discharge for patients given warfarin therapy to help reduce the risk of complications.

The hospital had implemented a medicines dashboard available on all wards, which highlighted TTO status in real time to support discharge planning and patient flow, and included various patient safety parameters. Dashboard data was updated daily at 1pm. From January 2026, we saw that the dashboard metrics had been validated and shared with heads of nursing with plans to incorporate them into a monthly medicine’s optimisation report. In January 2026, the pharmacy dispensary introduced a critical medicines dashboard that highlighted any critical medicine that was not in stock, due or overdue. Therefore, missed dose alerts were generated automatically through the e-prescribing software whenever critical medicines were recorded as missed due to no stock.

The hospital had an antimicrobial stewardship (AMS) team, which comprised 2 consultant microbiologists and an antimicrobial pharmacist. Stewardship activities included infection management advice, a telephone-based microbiologist advice service, and a daily microbiology round with intensive care unit clinicians. However, routine and microbial stewardship AMS prescribing quality and appropriateness audits had not been undertaken due to workload pressures and capacity limitations on the service impact. As such, the hospital could not fully demonstrate delivery against its own priorities or effective antimicrobial stewardship. The AMS team also had a vacant consultant microbiologist post between July 2023 and February 2025. Leaders acknowledged that prolonged senior clinical vacancies in microbiology were a recognised trust risk to AMS programme continuity, infection prevention support and outbreak management. This recruitment concern had been entered onto the trust’s risk register for management.

Also, while pharmacy technician staffing was described as good, pharmacist staffing was described as more pressured. The service used to use locum pharmacists more extensively, but budget constraints had reduced this and increased reliance on bank staff.