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13 August 2025
- The purpose of the assessment was to follow up on the warning notice served under Section 29A of the Health and Social Care Act 2008 which was issued to the service following our assessment in July 2024.
- We found improvements had been made in the majority of areas we reviewed. However, further work is required some areas and we will expect the service to provide us with quarterly action plans to demonstrate further improvements.
This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.
Learning culture
Score: 2
We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.
Safe systems, pathways and transitions
Score: 2
During our previous assessment in July 2024, we found waiting times within the emergency department (ED) were not visible on arrival or at any time through the patient's journey through the ED. Patients experienced long waiting times after their initial triage to then be seen by a clinician, during our assessment this was often in excess of 12 hours. On assessment we saw mental health patients experiencing long waits for transfer to specialist mental health services outside of the hospital. We found on this assessment waiting times were still not visible for patients at anytime in their journey through the ED. We found patients still experienced long waits following their initial triage to see a doctor. There were 34 patients in the waiting room at the time of our observation and there was a 10 hour wait to see a doctor. Staff told us they felt stressed as the waiting room was always very busy and there were always long waits to see doctors, which caused some patients to become frustrated with staff. There was security in the area 24 hours per day, 7 days per week. There were 7 patients who had a decision to admit in the initial assessment area including one mental health patient who had been waiting for a bed for 46 hours. The initial assessment area had a `fit to sit' area with 13 chairs. This room lacked any privacy and was very cramped with the `fit to sit' chairs being very close to each other. The length of stay for mental health patients in the ED over the previous 6 months up to May 2025, averaged 23.4 hours for adults and 15.3 hours for young people. The longest waits in the last 6 months included a wait of 165 hours for an adult, and 171 hours for a young person. This was not significantly different to the waiting times experienced by mental health patients reviewed during the last assessment. Most commonly long waits were due to waits for a mental health bed at other hospitals, or social care placement.During the previous assessment in July 2024, we observed, and staff confirmed they could not always provide one-to-one, or two-to-one observations for mental health patients as recommended following assessment by the psychiatric liaison team, due to having insufficient staff. On the day of the assessment there was only one registered mental health nurse (RMN) on duty despite three being scheduled to work. Healthcare assistants (HCAs) from other areas were called to support Majors, however with 17 mental health patients in the department at one time, despite more RMNs coming in, there were still insufficient staff to carry out the one to one and two to one observations required. This presented a serious riskDuring our follow-up assessment, we found staff were unable to obtain any of the 6 RMNs they requested on the day of assessment. However, we observed that all 7 patients were receiving one-to-one care, provided by HCAs brought in from other areas of the hospital. Staff confirmed that they would always provide one-to-one or two-to-one observations for mental health patients when necessary. One HCA told us that on rare occasions they might support two patients, but only when both were located within the same area. During the previous assessment in July 2024, we found there was not always a strong awareness of the risks to people across their care journeys. The approach to identifying and managing these risks was not always proactive and effective. Staff followed sepsis six guidelines to manage adults and children with sepsis. However, records we reviewed showed poor staff compliance with sepsis pathways. We also found the trust's sepsis ED guidelines had a review date of 2021 from its last review in 2018. The trust did not audit patient records. Care and support were not sufficiently planned and organised with the users of the service in mind. The service was at times overrun with patients many of which were being cared for in the corridor.During our follow-up assessment, we reviewed 17 sets of patient notes and found staff were following sepsis six guidelines to manage adults and children with sepsis and were compliant with the sepsis pathway. We reviewed the observation and escalation policy and noted it was now due for review in October 2027.Whilst improvements had been made, we found the issues identified in our previous assessment regarding overcrowding, caring for patients in the corridors and long waiting times in the waiting room and in the department had not been fully resolved. The trust had created a "decision to admit" corridor area at the back of majors. In this area patients who had been declared as requiring an inpatient stay were housed until a bed within the hospital was available for them. The area had hospital beds lined up along a corridor, each bed had a curtain for privacy and access to a call bell to alert staff if assistance was required. However, there was only one mixed sex toilet and shower facility for 17 beds and there was no attempt made to separate male and female patients.Patients were being routinely provided with food and hot drinks in the corridor and the decision to admit corridor. All patients we spoke with who had been in the department for more than 5 hours had been offered food and drinks.Patients waiting to be triaged were being processed in a more timely manner but were still not being triaged within 15 minutes of arrival in the department in line with national guidance. Patients arrived at the front entrance and were requested to take a ticket. They then waited to be called to the counter to be booked in. They then waited to be triaged.We observed for over an hour in the waiting room and followed the progress of 4 patients who arrived and took a ticket. None of those patients were triaged within 15 minutes of arrival. All were in the department for over 35 minutes before triage, with the longest being 48 minutes. However, all patients were triaged within 15 minutes of being booked in. The booking in process was delaying patients being triaged. The provider told us that an electronic self-booking in system was scheduled to be in place before the end of the summer.
We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.
Involving people to manage risks
Score: 2
During our previous assessment, we found the service routinely were unable to provide the support advised by the psychiatric liaison team because of insufficient numbers of staff available to provide one to one or two to one nursing.During our follow up assessment, we found that although the provider had been unable to obtain any of the 6 registered mental health nurses (RMN) the psychiatric liaison team had requested on the day of the assessment, we observed all 7 patients had one to one staff with them. Healthcare assistants were brought in from other areas of the hospital to provide this support. Staff we spoke with said they would always provide one-to-one, or two-to-one observations for mental health patients as needed. One HCA said on rare occasions they might need to support 2 patients on one to one, but both would be in the same area together for them to do this.Nursing staff had only received a basic level of training in mental health. The HCA staff who were providing one to one support, said they had not had any specific training in mental health or de-escalation. Senior staff indicated they were planning to arrange for this training to be provided for staff supporting mental health patients in the ED. The trust provided details of forthcoming training for staff with topics including suicide and self-harm, mental health legislation, simulation training, enhanced care, and ligature risk and use of cutters.During the previous assessment, the trust had an observation and escalation policy which covered the deteriorating patient, however this had not been updated since it was approved in December 2018 and the policy stated that it should be reviewed every 3 years after the approval date. The trust told us an updated policy was currently going through the consultation process before going to the trust's policies committee for approval.During the follow up assessment, we reviewed the observation and escalation policy and found it had been reviewed, it was in line with current guidance and was next due for review in October 2027.
Safe environments
Score: 2
We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.
Safe and effective staffing
Score: 2
We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.
Infection prevention and control
Score: 2
- During the previous assessment, we found there was not an effective approach to assess and manage the risks of infection that was in line with current relevant national guidance. Clinical staff were not always changing their gloves, washing their hands or cleaning equipment between patient care. We observed three members of staff who were not bare below the elbow. We raised these concerns with the hospital leadership after the first day of the assessment but did not see any improvement during the second day of assessment.
- During the follow up assessment, we found staff were using hand hygiene protocols, they were changing gloves and washing their hands prior to and between patient interactions. All staff we observed were bare below the elbow.
Medicines optimisation
Score: 2
- During our previous assessment, we found time critical medicines were not always given on time. We saw delays in the initial administration of antibiotics and Parkinson’s medication. Staff told us administration of other time critical medicines such as insulin were often delayed. We could not be assured that time critical medicines were always given in a timely manner.
- During our follow up assessment, we found the provision of time sensitive Parkinson’s medications performance required some further improvement. The performance was measured as administration within 2 hours, however, timely administration of Parkinson’s medication was generally considered to be within 30 minutes. The service had established a medicines management task and finish group that would continue to review performance going forward.
- Performance of all medicines given within 2 hours was at 92%, which shows an improvement since January 2025 which was at 80%.
- During our previous assessment, we found patients were self-administering their own medication and kept their own medication on them as there was no allocated storage system. The service had an out of date self-administration policy and staff could not describe how they would use it to support patients in the ED.
- During our follow up assessment, we found the self-administration policy described how patients and staff should handle patients own medicines. The policy was in date and contained the relevant required information. Staff we spoke with were aware of the policy and the process for patients self-administering their own medications.