Newham University 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 prioritised and that leaders had embedded a culture of openness and collaboration. We checked that people were protected from abuse and avoidable harm, and that there was a positive safety culture in which incidents were investigated and learning was embedded to improve practice. Staff were open and honest when things went wrong. However, delays in triage and assessment, and inconsistent completion of risk assessments and clinical documentation, increased risks to people’s safety.

At our last assessment, we rated this key question as requires improvement, and this rating has remained requires improvement. This indicates that some aspects of the service were not consistently safe and that further improvement was needed to strengthen safety. As a result, people may not always have been fully protected from avoidable harm.

The service was in breach of legal regulation in relation to safe care and treatment and staffing.

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.

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. Lessons were learnt to continually identify and embed good practice.

The service had a positive learning culture, where staff understood the importance of reporting incidents and learning from them to improve safety and experience. Staff described how they escalated concerns and reported incidents. Incident data we reviewed highlighted themes around pressure ulcers, violence and aggression, patients absconding, and delays in care. The service demonstrated a well-established and structured approach to learning, supported by the implementation of the Patient Safety Incident Response Framework (PSIRF). Incidents were reviewed through a daily triage process, with allocation of learning responses and early identification of themes. This facilitated learning from incidents, ensured that issues were addressed promptly, and helped to spot recurring patterns early, supporting timely interventions.

We observed that learning was a part of day‑to‑day practice in several areas. For example, nursing handovers featured matrons' messages highlighting best practice from past audits and a hot topic aimed at enhancing clinical practice. We saw that changes were made in response to learning from incidents, such as changes to pathways and guidance. This learning was supported by multidisciplinary simulation.

Staff told us that safety discussions took place within teams and that learning from incidents was shared informally during handovers and safety huddles. This was also communicated through governance newsletters, mortality and morbidity reports, and visual displays. Leaders reviewed incidents and used this information to inform changes in practice, such as increased observation of people at risk of deterioration and additional support for people not yet safe for discharge. These processes supported a culture of openness and continuous improvement.

When things went wrong, staff apologised and gave patients honest information and suitable support. We saw examples of thorough investigations of incidents being undertaken and examples of where duty of candour had been applied.

However, we observed some inconsistency in the sharing of learning within the service. For example, following an incident in the Clinical Decision Unit (CDU), procedures were implemented to ensure daily handovers included completion and follow-up on falls risk assessments. However, this approach had not been extended to other areas of the emergency department, where patient records demonstrated several incomplete or unaddressed risk assessments.

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

The service had systems and pathways in place to manage people’s movement through urgent and emergency care. However, these systems were under significant pressure and did not always work effectively. Due to crowding and pressure on the capacity of the emergency department, there were not always safe transitions for people.

Patients were allocated to different areas of care depending on the severity of their condition: the resuscitation unit, majors, Same Day Emergency Care (SDEC), Urgent Treatment Centre (UTC) and the MAJIC bays (ambulatory/fit-to-sit).

In both triage and the waiting area, patients frequently faced lengthy delays. Administrative staff were responsible for the initial booking-in process, but with only 2 administrators available at times, we witnessed queues forming as patients waited to be registered. The service did not have a navigator or streaming nurse present at reception. This meant patients who needed to be redirected to alternative care areas outside of the service faced avoidable delays before their transfer. We observed instances where the time taken to triage exceeded 40 minutes, this fell short of the Royal College of Emergency Medicine (RCEM) guidance, which recommends triage within 15 minutes, compromising the effectiveness of early risk identification and timely intervention. However, at the time of our inspection the hospital was at Operational Pressures Escalation Level (OPEL) 4. This is the highest level of escalation within the NHS OPEL framework. It indicates that demand significantly exceeds capacity, and an organisation is unable to deliver comprehensive services safely without implementing urgent system-wide actions. An Emergency Department (ED) front door redesign programme was launched in late 2025, resulting in sustained reductions in delays at ED front door. However, leaders recognised and our observations demonstrated, that there was variability in timeliness of triage during periods of peak operational pressure.

During our inspection we observed that there was also limited oversight and monitoring of the waiting areas increasing the risk of delayed recognition of urgent needs, and reduced access to timely assistance. In response to our inspection feedback, the service planned to introduce a dedicated 24/7 registered nurse role to oversee the waiting room. This was intended to support active monitoring of patients awaiting assessment or treatment.

Walk-in patients were triaged and assigned an acuity score by a nurse in the primary assessment. Secondary assessment had a doctor who would perform a rapid assessment and treatment for those not streamed to local GP services or urgent care centres. Staff demonstrated familiarity with protocols for identifying patients at risk of deterioration and consistently remained alert for indications of sepsis. Patients presenting with a high acuity score or a national early warning score (NEWS2) of 5 or over had blood tests ordered and were promptly escorted by triage nurses to the secondary assessment area.

The service did not always have a doctor allocated to rapid assessment and treatment (RAT) to assess patients arriving by ambulance promptly. This meant early assessment, treatment, investigations, and direct referral were not always initiated in a timely way.

As a result, this did not consistently meet expectations of early senior decision-making at the front door. However, this process was being reviewed, with a specific focus on protecting senior decision maker presence.

Patients who had been admitted to the emergency department with both physical health needs, and mental health needs were held in the department for too long, sometimes for several days. For instance, although stays in the CDU were intended to last no more than 24 hours, we spoke with patients who had remained there for up to 3 days. Challenges with bed availability affected timely movement through pathways. Some people waited several hours for medical review, and there were occasions where people remained in waiting areas or corridors for prolonged periods. Patients experienced extended waiting periods at night, with some reporting delays exceeding 9 hours before seeing a doctor. This created congestion and reduced the effectiveness of streaming pathways. Corridor care was observed during busy periods, which increased risks to safety, dignity and privacy, particularly for people with frailty, mental health needs or complex conditions. Patients receiving care in corridors had access to one of the major cubicles for personal care, which helped support privacy and dignity. Although daily flow meetings and escalation processes were in place, these were not always sufficient to prevent bottlenecks. However, when corridor care was in use, additional bank staff were deployed and patients were cared for in a corridor area surrounding the nursing station, which helped maintain staff visibility and oversight.

There was variation in staff understanding of the circumstances in which patients should be streamed to services such as Same Day Emergency Care (SDEC), urgent care and the Clinical Decision Unit (CDU). Some staff told us there was established inclusion and exclusion criteria however others told us this was under review. Staff showed us a SDEC & CDU Standard of Operation document, which was effective from June 2024, however this did not appear to have been approved.

The SDEC operated a shared model of care between medical and surgical teams, with a surgical resident doctor linked to the service to support day-case pathways such as incisions and drainage. Staff told us there was automatic acceptance of suitable surgical patients to support patient flow within the ED. SDEC bay 3 was operating as medical SDEC between 9am and 5pm seeing a mix of planned returns (for example, booked follow-up patients) and patients with new medical presentations.

The service had clear pathways for patients attending the ED with mental health needs. ED nurses also referred patients to the psychiatric liaison team as needed. There was inconsistent compliance with national guidance on time to be seen by psychiatric liaison following referral in ED. Although all patients referred to psychiatric liaison were seen within 24 hours, national guidance expects a response within 1 hour of referral and an appropriate response or care package within 4 hours of ED arrival or ward referral. Data showed ongoing delay pressures, with average 4-hour breaches of 25% and 12-hour breaches of 14% over the last 6 months, indicating that timely psychiatric liaison assessment and onward management were not consistently achieved for all patients.

The provider also had a pathway for children or young people presenting to the paediatric ED with mental health needs. This involved referral to the Child and Adolescent Mental Health Services (CAMHS). The CAMHS liaison service worked 9am-9pm, but overnight cover was provided by staff covering 3 different sites, often carrying out telephone assessments including for patients post overdose. Staff said that twice weekly there was no CAMHS out of hours service, which created a risk that children and young people with mental health needs may not have received timely, face-to-face specialist assessment and support when they needed it.

The provider worked in partnership with a local mental health trust to support patients with mental health needs, with a psychiatric liaison team available 24 hours a day and 2 staff on site. ED staff reported good access to the team for advice and assessment. In addition, the service had an enhanced care team of trained mental health staff who provided therapeutic interventions and could be requested to support patients requiring one-to-one care, including those with acute mental health needs, drug or alcohol intoxication, risk of wandering or absconding, psychological distress, or risk of harm to themselves or others. Despite this, we observed long stays for some patients with mental health needs, typically due to delays in transfer to specialist mental health services. Leaders were working with the local mental health trust to address these delays.

Discharge processes were in place, and staff provided patients with advice about next steps and follow‑up care. However, delays in decision‑making and limited onward capacity meant some patients remained in clinical areas longer than necessary. The service liaised effectively internally with speciality teams and externally with other health care providers to ensure there was always continuity of care when people moved between different services.

The 7 day reattendance rate is a national A&E Clinical Quality Indicator, commonly used to reflect the safety and effectiveness of the initial care and discharge from the ED. Between April 2025 and March 2026, the average reattendance rate within 7 days of the initial ED visit was 9.8% for the paediatric ED and 11.1% for the main ED, which was in line with the national average.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

The service had safeguarding systems and policies in place to protect people from abuse and neglect. The staff in the emergency department showed a good understanding of safeguarding and how to take appropriate and immediate action when needed. Staff knew how to make a safeguarding referral and who to inform if they had concerns. The service had safeguarding leads and staff found them approachable and supportive.

In paediatric areas, staff showed a clear understanding of safeguarding risks, including non‑accidental injury, repeated attendances and mental health presentations. Staff used systems to identify previous attendances and safeguarding concerns and ensured information was shared with relevant professionals, including general practitioners, health visitors and school nursing services where appropriate. Consent and capacity, including Gillick competence, were considered appropriately when caring for children and young people.

In adult areas, staff recognised safeguarding risks associated with frailty, falls, mental health and prolonged stays. There was due regard given to possible abuse or neglect for people. Staff told us they would refer something to the safeguarding team if they were unsure. They had no concerns about speaking up for people and this included those who accompanied a patient who gave rise to concerns about themself or others. They were supported to act in the best interests of patients and to ensure their safety.

Staff understood their responsibilities in relation to the Deprivation of Liberty Safeguards (DoLS) and told us these were only used when necessary and in the best interests of the person. Safeguarding systems and practices in the department supported the protection of people’s human rights and helped to ensure that no one experienced discrimination.

Staff received training specific for their role on how to recognise and report abuse. Most staff had completed the right level of safeguarding training for both children and adults. Compliance with level 3 safeguarding training for adults and children was at an average of 67.1% and 71% respectively across staff groups. The trust had an agreed trajectory to achieve 85% compliance by the end of September 2026.

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

We found incomplete and inconsistent clinical documentation across many of the patient records reviewed. This included gaps in documentation and instances where risk assessments had been completed but actions to mitigate identified risks had not been taken. This meant that risks to patients were not always recognised or managed effectively, which could compromise patient safety. Senior nursing staff told us this was a known issue; however, improvements had not been fully embedded at the time of inspection. Leaders identified the consistency and quality of clinical documentation and risk assessment processes as a priority and included this as a core workstream within the service’s quality and safety improvement programme. Following the inspection, leaders told us they had taken immediate action in response to feedback. This included implementing senior reviews of documentation, increasing spot audit activity, and introducing daily monitoring of compliance, which was recorded within handover documentation.

Staff were able to describe the process of managing deteriorating patients. We observed staff monitoring patients through regular observations. We found that pressures on the service, such as crowding and increased workload, constrained staff capacity to reliably document patient observations. For instance, a single nurse was observed caring for 29 patients simultaneously in the SDEC, which restricted the ability to perform, record, and respond to patient observations promptly.

Data we reviewed from the service deteriorating patient dashboard showed that staff use of early warning tools to identify and respond to deterioration was inconsistent. This created avoidable risk if concerns were not recognised early or escalated reliably. Senior leaders told us the low compliance with recording of NEWS2 and paediatric early warning scores (PEWS) was partly because staff were more often checking only 1 or 2 vital signs, instead of recording a full set of observations each time. While compliance in the adult ED was 79.2%, the risk was more pronounced in paediatrics. Where compliance in the 3 months prior to the inspection for recording full vital signs averaged 6.8%, meaning PEWS were frequently not calculated. The data submitted demonstrated low performance since January 2024 (8.9%) and showed a worsening trend. The trust acknowledged that recording full sets of paediatric observations was more challenging than for adults. Future interventions from a quality improvement project designed to address this included the introduction of a new tool and enhanced staff education to support completion.

There were poor rates of compliance with sepsis screening. Compliance with sepsis screening for patients meeting an early warning trigger averaged 6.3% in the 3 months prior to the inspection and demonstrated limited improvement since September 2021 (5.6%). The senior leaders informed us that patient electronic records indicated sepsis screening was completed for a much higher proportion of patients. However, this was not always recorded through the process used to populate the deteriorating patient dashboard. The trust said this was being audited separately to provide assurance on compliance with sepsis assessment requirements. Despite these concerns, we did not see any evidence from patient incidents or the cases presented to the hospital’s deteriorating patient working group that patients had come to harm as a result of this low compliance.

The service had support from the hospital medical emergency team to help manage deteriorating patients, which improved its ability to respond promptly and provide appropriate care. Leaders informed us that increased staffing in the hospital’s critical care outreach team had led to increased responsiveness and supported the earlier identification of deterioration.

Patients were able to see approved mental health nurses for assessment under the Mental Health Act 1983, promptly, including at night. In the 6 months to the end of April 2026, 70 patients with mental health presentations had absconded from the ED, with sufficient concerns for their safety or others to involve alerting the police. Although none of these incidents resulted in significant harm, they increased the risk that patients in crisis could leave before receiving the care, treatment or supervision they needed. This meant the service could not always ensure that patients at risk were kept safe or appropriately supported while waiting for assessment.

In paediatric areas, staff involved parents and carers in assessments and decisions. Staff used age‑appropriate communication and ensured parents understood treatment plans and discharge advice. Pain relief was given promptly, and staff explained what to expect and when to seek further help.

Staff in the paediatric ED told us they were seeing an increasing number of patients presenting with mental health needs, including drug-induced psychosis, but noted they had not received training in managing these cases. As a result, some staff felt ill-equipped to respond appropriately to mental health crises, potentially increasing the risk to both patients and staff. This was particularly significant as, since October 2025, the paediatric ED had cared for 16 and 17 year-olds. Data we reviewed showed that in April 2026 there were 42 attendances relating to mental health presentations in the paediatric ED, 40% of which were for those aged 16 and 17. Although some nursing staff were trained in de-escalation, staff told us only security staff were permitted to carry out physical restraint on patients. Staff said security staff were reluctant to use physical holds, especially with children. Staff also described a recent incident when they had to call police to restrain a child patient. This could delay an appropriate therapeutic response, increase distress for children and young people in crisis, and reduce the service’s ability to manage escalating risks safely.

Patients and their carers were given opportunities to express their feelings and share what was important to them. We noticed that staff allowed individuals and their loved ones to communicate their specific needs and concerns, making every effort to be understanding and reassuring.

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

The premises and facilities supported the delivery of safe care although staff and leaders recognised that there was insufficient space for the demands on the service. Most clinical areas were clean, and equipment such as resuscitation trolleys were checked regularly and found to be in date and complete. Most furniture and fixtures were found to be in satisfactory condition; however, 2 damaged stools with the fabric torn and the lining removed were noted in the paediatric waiting area, which impeded effective cleaning.

There were several designated spaces for patients awaiting assessment, treatment, or transfer. The primary waiting area was not entirely observable from the reception desk and triage cubicles. Although CCTV coverage was available for the waiting area adjacent to the reception desk, it was observed that administrative staff were focused on patient registration and generally did not have the capacity to actively monitor the CCTV feed. The SDEC waiting area was in a separate room to other SDEC areas, with limited staff visibility. In response to our inspection feedback, the service was introducing a dedicated 24/7 registered nurse role to oversee waiting areas. This was intended to support active monitoring of patients awaiting assessment or treatment.

Some clinical areas appeared cluttered, particularly during busy periods, which made cleaning more difficult and increased the risk of trips and infection transmission. Throughout the ED we found that storerooms used to store medicines and equipment were not locked and that some hazardous substances were not stored securely. It was also observed in the urgent care centre for injuries that treatment room doors storing equipment, including needles and scissors, were left propped open without any staff supervising the area.

The paediatric emergency department was co-located but physically separate from the main ED. It could be accessed by authorised persons via a swipe card or the intercom. There was a separate paediatric waiting area inside the department. Within the resus area of the main ED there was a dedicated bay for children and young people, however, this was frequently used by adult patients. There was a high dependency cubicle within the paediatric ED. This was often used to take priority calls and for resuscitation and stabilisation when the paediatric bay in the main ED resus was occupied by adult patients. We observed that when the paediatric resus bay was in use by an adult patient this would be communicated to staff via the department tannoy system. This was recorded on the service risk register as a high risk. Controls included using the high dependency cubicle and identifying adult patients in resus who could be stepped down to make the paediatric resuscitation bay available for children.

Diagnostic imaging facilities were co-located in the department which allowed for diagnostic procedures to be completed quickly if patients were waiting for a specialist review.

The enhanced care unit provided facilities for people with mental health needs. The layout provided more privacy for mental health patients who could be monitored in a more discrete unit. All possible ligature anchor points and ligatures (such as wires) were removed from cubicles/rooms before patients at risk were placed there. However, patients could not be left in these areas without supervision, which impacted upon their privacy, particularly during long stays. The trust had carried out ligature risk assessments and there were plans to carry out further ligature reduction work. There were 2 ligature free rooms in majors (P1/P2) which were frequently used for patients with mental health needs. The paediatric ED had 2 rooms for children and young people with mental health needs; these were ‘ligature light’ rooms with some sensory equipment. Staff in both departments said some mental health patients could present difficulty with other physically vulnerable patients nearby. Non-ensuite rooms meant patients had to be escorted through these areas to toilet facilities, and children over 16 exhibiting behaviour that challenged might be moved to an adult assessment room.

We checked equipment for Portable Appliance Testing (PAT) in ED areas visited and found that most equipment was tested yearly. Staff carried out daily safety checks of specialist equipment. We reviewed a selection of supplies in trolleys in ED areas and found most to be in date.

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, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

The provider had skilled and committed staff who worked hard to keep people safe. Staff were trained and competent in their roles. However, staffing levels were not always sufficient to meet demand, particularly during busy periods.

The service planned and regularly reviewed staffing levels and skill mix; however, staffing data indicated a total vacancy rate of 22.1%. NHS staff survey responses reflected these shortages, only 18.1% of staff in the service said there were enough colleagues to do their jobs properly, compared with 35.3% across the hospital.

Temporary staff were used to ensure safe staffing levels and manage corridor care safely. Data showed overall staffing fill rates were below planned levels at times in the year prior to the inspection, although this varied across clinical areas and staff groups. More detailed data showed that the urgent care centre (UCC) operated slightly below planned registered nursing levels, with daytime fill rates ranging from 85–91%. Unregistered staffing in the paediatric emergency department also showed some variation, with fill rates between approximately 71–77% in certain months. However, the service took action to manage risk through adjusting staffing levels particularly by increasing workforce overnight or in response to demand.

Medical staffing data showed a shortfall in resident doctor cover. Data we reviewed showed total fill rates ranged from 67% to 73%. Gaps were evident across all shift types but were more pronounced on late and night shifts. Temporary staff were used to help fill some of these gaps. Gaps were also seen within the advanced clinical practitioner (ACP) workforce due to vacancies, where staffing levels were below plan across all months between January 2026 and April 2026, operating at approximately 26–30% of required levels during the day and 54–93% at night. As ACPs were rostered as part of the medical staffing model, cover was supplemented by medical locums where needed.

Leaders used escalation processes and redeployed staff where possible, including using locum staff and where needed drawing on staffing from other services. However, these measures did not always fully address gaps. Alongside this, leaders introduced systems to manage day-to-day pressures, including divisional staffing calls to mitigate short-term gaps.

Consultants were present in the ED from 8am to midnight every day, aligning with the Royal College of Emergency Medicine (RCEM) guidelines for 16 hours of coverage daily. Outside these hours, overnight shifts moved to a non-resident on-call system. Staff described that there was a consultant presence in the paediatric ED but that this could be inconsistent. Data we reviewed showed a consultant should be allocated to the paediatric ED on a day and late shift on weekdays and a consultant allocated to cover SDEC and the paediatric ED on a weekend. However, due to pressures in the adult ED this often meant the ED consultant allocated to the Paediatric ED was also covering other areas of ED and not quickly available to the patients and staff in paediatrics.

Health care assistant (HCA) staff explained that they used to work exclusively in specific departments such as the ED or Urgent Treatment Centre (UTC). However, after being required to rotate through all urgent and emergency care areas, they felt unsupported when placed in unfamiliar settings and reported not receiving an adequate induction. Although staff raised these concerns with leadership and study days were held, some still felt unprepared for working in less familiar areas.

Staff and leaders recognised that the service was under-resourced relative to demand. Fortnightly workforce meetings occurred to maintain oversight of recruitment. Leaders articulated a strategic approach to aligning staffing with demand. They described undertaking detailed capacity and demand modelling across both medical and nursing workforces, which identified a mismatch between current staffing levels and service requirements and confirmed that a business case has been developed to address this gap for medical staffing. A lack of senior medical staff within the ED was recorded on the service risk register as a medium risk. Leaders described a longer-term plan to develop a more senior-led workforce model to strengthen decision-making, patient flow and outcomes. The trust informed us that they were undertaking a review of staffing against activity, acuity, and arrival patterns to better align workforce capacity with periods of peak demand.

The ED had access to an enhanced care team available to therapeutically support adults with mental health needs. The team consisted of a registered mental health nurse and 3 mental health support workers employed by the local mental health trust during the day. At night the area was staffed by 2 bank mental health nurses. Senior staff informed us there was an ambition for this provision to be extended to support children and young people, although there was not a timeframe for this to occur.

There was good access to training and support for staff. Several resident doctors we spoke with praised the quality of education, guidance and support from their consultant colleagues. There were teaching sessions each week and simulation training usually monthly. Most staff commented positively on access to training opportunities. However, it was reported that staff in the paediatric ED had access to fewer training opportunities.

Most staff groups had good mandatory training compliance and met the trust target of 85%. However, training data for medical staff was not consistently up to date, particularly for immediate life support (ILS). Data showed a significant number of medical staff had not completed required life support training to manage life-threatening emergencies. Compliance rates were low, with paediatric immediate life support at 7.4% and immediate life support at 1.5%.

Senior leaders told us that recorded compliance did not fully reflect the competence of resident doctors, as many were likely to have completed relevant training at other organisations prior to rotating into the trust. While leaders expressed assurance regarding the capability of the medical workforce, they acknowledged limitations in how training was recorded and overseen for rotating staff. As a result, the service could not consistently demonstrate that all medical staff were appropriately trained and up to date to respond to life-threatening emergencies.

Not all staff were receiving regular appraisals, which should provide opportunities to discuss development, progression and learning needs. Overall appraisal compliance was 46.8%, which fell well below the trust target of 90%.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

The service had infection prevention and control systems in place, and staff followed good practice in most areas. Clinical areas were generally clean, and staff had access to hand hygiene facilities and personal protective equipment.

Infection prevention and control (IPC) performance showed mixed results, with evidence of both improvement initiatives and ongoing risks to effective practice. Blood culture contamination rates in March 2026 were 5.7% in the emergency department, exceeding the national benchmark of 3% and indicating weaknesses in aseptic non-touch technique and hand hygiene. Monthly hand hygiene audits further reflected inconsistency, with overall compliance fluctuating between 68% and 86%. The service had implemented a range of improvement actions, including peer auditing, targeted education, strengthened audit validation, and increased visibility of expectations.

‘I am clean” stickers were in place on equipment to indicate they were clean and ready for use. However, some stickers had not been updated from the previous day. Some patients also commented that their bedspaces had not been cleaned over their stay.

Personal protective equipment (PPE), hand sanitisers, and hand-washing stations were easily accessible throughout the department. Staff mostly adhered to a bare below the elbow policy. Signs encouraging proper hand hygiene were visible, including reminders to remove gloves to prevent improper glove use. Most staff cleaned their hands between patient interactions, though some were observed decontaminating their hands less frequently. Staff reported ongoing collaboration with the site's infection prevention and control team to further improve compliance with infection control practices.

The service mostly assessed and managed the risk of infection. Any patients who were tested as positive or showing signs of infection which could be passed to others were isolated as soon as possible.

Domestic staff who were working hard to maintain a clean and well-maintained department in a busy part of the hospital. They confirmed that they had received training to work in their role. We observed there were dedicated waste disposal areas for different types of wastes including infectious waste. During our inspection we also observed sharps bins were assembled correctly and used appropriately.

The service ensured people received their medicines safely however documentation practice was not always consistent.

Patients usually received their medicines safely and as prescribed. Records reviewed showed that medicines were administered in a timely way, including time critical medications.

Controlled drugs (CDs - medicines requiring more control due to their potential for abuse) were stored securely, with access restricted to authorised staff. However, stock medications were not always stored securely. Access to treatment rooms was controlled via swipe card access; however, we found medication cupboards left open in several treatment rooms. This increased the risk of unauthorised access or diversion of medicines.

Daily temperature checks for treatment rooms and medication fridges were not consistently completed. Without routine monitoring, the service could not be assured that medicines were stored within recommended temperature ranges, which may compromise medicine stability and effectiveness.

Although the trust did not meet the Royal College of Emergency Medicine (RCEM) guidance for pharmacy staffing, there was dedicated pharmacy support to ED 5 days a week. We saw evidence of clinical interventions by pharmacy staff that supported safe prescribing and medicines optimisation. The trust reported that, on average, 59% of patients admitted to the Clinical Decision Unit received medicines reconciliation by a pharmacy professional within 24 hours. The trust recognised that additional staffing would support more consistent delivery of timely medicines reconciliation.

We saw evidence of good antimicrobial stewardship principles, including prescribing in line with local antimicrobial guidelines and clear documentation of review dates. The pharmacy department had a service in place that prompted review of restricted antimicrobials. These practices helped promote the safe and effective use of antibiotics and reduced the risk of antimicrobial resistance.

The process for recording the use of over labelled To Take Away (TTA) packs was inconsistent across the ED service. In one area a record book was used to record the supply of TTA packs, requiring 2 staff signatures. However, this process was not followed in other areas, despite the presence of a record book. In these areas, nursing staff told us that administration of TTA medicines was documented within individual patient records. The lack of a consistent process limited oversight of safe and appropriate use of TTA packs.

Documentation relating to venous thromboembolism (VTE) prophylaxis was not always completed. Pharmacy staff told us there was a process to identify patients who had not received VTE prophylaxis, with these patients flagged to ward pharmacy teams for follow up. However, we reviewed 6 patient records and found that 5 did not have the appropriate completed VTE prophylaxis assessment on their notes, despite 2 being prescribed treatment. We could therefore not be assured that VTE risks were being assessed appropriately.

Where medicines were used to manage patients with agitation, nursing documentation did not consistently demonstrate if de-escalation techniques were considered prior to administration.

The trust had a system in place in which electronic prescriptions were sent to patients nominated pharmacies, all staff we spoke with found this helped the discharge process and ease of accesses of medications.