Central Middlesex 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 is the first assessment for this service. This key question has been rated good.

This meant people were safe and protected from avoidable harm.

The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly and patients were protected and kept safe. The service worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff managed medicines well and involved people in planning any changes. However, the service did not always assess or manage the risk of infection well.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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 culture of safety and learning. There was a no blame approach which empowered staff to report any issues without fear of negative consequences. Staff understood their responsibilities to raise and record safety incidents, concerns and near misses, and were encouraged to do so by senior leaders. Staff reported incidents through an electronic system which could be accessed by all staff, including bank and agency staff. The service had reported no serious incidents for the previous 12 months.

The service ensured that lessons were learned, and improvement was made when things went wrong. Staff received feedback on incidents they reported, and learning was shared through handovers, emails, and safety huddles, which were attended by both clinical and administrative staff. The trust had a culture of cross -site learning from incidents, where learning from serious incidents from all emergency departments within the trust were shared across all sites through a weekly emergency department newsletter. Learning from incidents was also a regular agenda item at team meetings.

We saw examples of how the service had implemented changes as a result of incidents. For example, we saw that an emergency response pathway had been put in place following a person who presented in established labour and gave birth at the urgent treatment centre (UTC), as the site does not have any maternity services.

All staff we spoke with could articulate the complaints and compliments process and would proactively share this information with people. The service had an up-to-date complaints policy in place. Each staff member, both clinical and administrative, would aim to gather written feedback from 10 service users each shift to capture any concerns or compliments. All feedback we saw during the assessment was positive. From July 2024 to June 2025 the service did not receive any formal complaints.

The trust had a culture of cross-site learning from complaints, where learning from complaints from all emergency departments within the trust were shared through a weekly emergency department newsletter, and any actions taken in response to complaints were implemented across sites. For example, the patient group for sickle cell patients gave feedback that they felt their voice was not heard in the emergency departments and there were delays in providing them with pain relief. In response to this the trust held a cross-site sickle cell week, to raise awareness of sickle cell disease and introduce ACT NOW, an NHS guide to improve clinical outcomes and care experience of patients in sickle cell crisis. At the most recent listening event there was lots of positive feedback relating to patients’ treatment and the time taken to receive analgesia.

Staff understood the duty of candour. They were open and transparent and gave patients and their families a full explanation if and when things went wrong. The service had an up-to- date duty of candour policy in place.

Risks were managed by senior leaders within the service. Senior leaders told us the top risks were staffing recruitment, and finance. This was reflected in the service’s risk register. Action plans were in place to mitigate the risk, including recruitment drives and the use of temporary staff to ensure shifts were filled.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The urgent treatment centre (UTC) only treated people with minor injuries and illnesses who self-presented, or were referred from 111. They did not accept any patients bought in by ambulance.

On arrival at the UTC, patients were booked in by reception staff, who immediately alerted clinical staff if a person appeared unwell or required urgent attention. Once booked in, patients were streamed and triaged by an emergency nurse practitioner (ENP) using a national triage tool. The Royal College of Emergency Medicine (RCEM) recommends all patients are triaged within 15 minutes of arrival. We saw the service achieved 97.4% compliance with this standard over the previous 12 months.

After triage, patients waited in either the adult waiting area or, if under 18, the separate secure paediatric waiting room, until they were seen by an ENP or a General Practitioner (GP). At times of high demand, clinical staff were deployed to reception and triage to undertake rapid assessments, ensuring patients were seen in a timely way. We saw that over the previous 12 months, 95% of patients were seen, treated, or referred within four hours of attendance which was above national accident and emergency targets.

Reception staff regularly updated people on current wait times. However, there was no signage available, including in other languages, to inform people of current waiting times.

The service used an electronic patient notes system that was used by hospitals, GP’s and other health services across the region. This meant staff could instantly access a patient’s previous notes when assessing a patient, and also allowed the service to instantly share notes with other services, for example a neighbouring accident and emergency department if a person required emergency transfer, or a specialist department if requiring a specialist service review such as paediatrics.

The computer system had an effective flagging system. We saw patients with dementia, learning disabilities and Parkinson’s disease flagged on the system. This alerted staff that these patients may require additional support while in the UTC. The system also flagged if any patients were at risk of sepsis and would not let staff proceed with documentation until the alerts had been acknowledged and addressed.

The service had an onsite x-ray department that was open from 8am to 8pm. Outside of these hours patients needed to attend a neighbouring accident and emergency department, or if clinically stable, could return the next morning.

The service was able to undertake basic point of care testing such as blood sugars and urinalysis. The service did not have an onsite pathology service, therefore any blood tests were required to be undertaken at other services, and results followed up by the patient’s GP. Although there was no mental health service at the hospital, the service had close links with the local mental health service and could seek advice and in person support if required.

The service had a transfer of care policy in place for patients who required higher level or more urgent treatment at an emergency department. Although not an emergency department, the UTC would initiate lifesaving treatment until the ambulance arrived to transfer the patient to another service. The site also had a critical care outreach team available for inpatient areas, who would attend the UTC if support was required for a critically unwell person. We saw the critical care team attend the UTC regularly during the assessment to offer support if needed.

During the assessment we saw an acutely unwell patient transferred effectively and without haste to an emergency department for further treatment, in line with the policy. We saw effective communication to the receiving hospital by a GP being undertaken simultaneously with an urgent request of an emergency transfer being made by another member of staff, while urgent care was being delivered by other staff.We saw staff not involved in the emergency situation were deployed to triage so that people continued to be observed and assessed within 15 minutes of arrival.

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.

There were systems, processes and practices in place to keep people safe, and these were well communicated to staff. Staff were aware of how to make safeguarding referrals to the local authority where necessary and spoke confidently about safeguarding issues including recognition of exploitation, gangs, and female genital mutilation (FGM). The electronic system flagged if a patient had a child protection plan in place, or if a patient frequently accessed services throughout the area. The trust had named safeguarding leads across the hospital who staff could access for advice regarding safeguarding matters. All staff we spoke with knew who the leads were and how to access them.

The service had an up-to-date safeguarding policy in place. Staff could give examples of how to protect people from harassment and discrimination, including those with protected characteristics under the Equality Act.

Most staff had training on how to recognise and report abuse, and they knew how to apply it. All medical staff had received Safeguarding Adults Level 3, and Safeguarding children level 3 training. All reception staff had received Safeguarding Adults Level 1, and Safeguarding Children Level 1 training in line with their role.

Not all nursing staff had completed safeguarding training at the required level. At the time of assessment, 57.14% of nursing staff had completed Safeguarding Adults Level 3 training and 71.43% had completed Safeguarding Children Level 3 training. As the nursing team was small, this equated to three members of staff. Leaders were aware of the gaps and explained they were linked to long-term sickness and recent staff appointments. We saw that staff without the required training were already booked onto upcoming sessions. All staff we spoke with were able to describe how to recognise and report safeguarding concerns.

All staff were aware of how to recognise people with learning disabilities and encouraged the use of individual care passports. These passports helped staff understand each patient’s specific needs and how best to support them while in the department. All staff knew how to refer a person to the learning disability team. Patients with learning disabilities were flagged on the electronic system, and the trust learning disability team would receive notification if the person had presented to the UTC so that they could follow up with the person if required. We saw 100% of staff had received Oliver McGowan Mandatory Training on Learning Disability and Autism.

Mental Capacity Act training was incorporated into the safeguarding training modules. We saw examples of staff assessing patient’s capacity, and documenting it within the person’s notes. All clinicians were able to articulate how they would assess a patient with mental health issues including the appropriate risk assessment. Although they did not provide a mental health service, the UTC had a two doored ligature light room available if required, while a patient was waiting a mental health assessment from the local mental health service, or transfer to another service provider.

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.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with people with communication difficulties. For example, in each examination room we saw posters for an available translation service for those people whose first language was not English, as well as hearing loop availability. All patients we spoke with told us they were involved with the decision making about their treatment. Patients, their families and carers, said the clinicians had been very helpful and explained things well.

Staff used a nationally recognised tool to identify deteriorating people and escalated them. Observations of vital signs were recorded by staff and the national early warning score (NEWS2 for adults, PEWS for children) was calculated. These were recorded electronically. The service had a clear escalation policy for the deteriorating patient, including the transfer of their care to an emergency department.

Staff knew about and dealt with any specific risk issues such as possible sepsis. All clinical staff received sepsis training, and the service had an up-to-date sepsis policy in place, including the transfer of their care to an emergency department.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service had 6 consultation rooms, 3 within the adult area, and 3 within the paediatric area. The service had a separate, secure, paediatric waiting area in line with Facing the Future standards. Treatment rooms in the paediatric area were often used to see adult patients. This meant adults had to walk through the paediatric waiting area in order to access these rooms. The service mitigated the potential risk to any children as the area could only be accessed by secure entry, and all adults were escorted by a member of staff for the entirety of their walk from the adult waiting room to the consultation room.

The service had an assessment bay which had three trolleys where patients requiring short term treatment such as nebulisers could receive their treatment. This area also allowed patients requiring closer observation and more urgent treatment to be adequately assessed and monitored while waiting transfer to an emergency department.

The UTC environment was well laid out, light and airy, and was visibly clean and tidy. Equipment was stored appropriately and well maintained. We saw evidence that all items had been regularly PAT tested. Staff knew how to report faulty equipment and told us that replacements were provided quickly. Where replacement equipment was not available at the Central Middlesex Hospital, it was sourced promptly from larger hospitals within the trust.

The service had a resuscitation trolley with both paediatric and adult equipment available to use in an emergency. We saw this was checked daily to ensure it was equipped and ready for use in the event of an emergency.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service planned and regularly reviewed staffing levels and skill mix to ensure people received safe care and treatment. Staffing requirements in the UTC were planned using guidance from the Royal College of Nursing and the Royal College of Emergency Medicine (RCEM). The service employed GPs, emergency nurse practitioners (ENPs), and reception staff in line with the function of an urgent treatment centre.

During our assessment we did not observe any staff shortages. All clinical staff were qualified in both paediatric and adult urgent care. There was a good skill mix of GPs and ENP’s on duty. Shift times were staggered to ensure more clinical and reception staff were available in the evening, when the UTC was busiest. We saw that staff were allocated to triage in two-hour time slots, which meant staff were rotated through the role, helping to reduce fatigue while also allowing staff to undertake patient assessments.

The service had a medical staff vacancy rate of 68%, and a nursing staff vacancy rate of 50%. Leaders told us that this was due to the recent change of service provider, and difficulties in recruiting specialist staff due to a national shortage. Recruitment plans were in place, and we saw the service was undertaking interviews for ENP’s on the day of our assessment. Leaders told us they used regular agency staff to fill the staffing gaps while recruitment was being undertaken. This was evidence by a 98% shift fill rate meaning that the service was very rarely short staffed.

All staff we spoke with told us they enjoyed working at the service. One member of staff, who had worked at the service over several decades, continued to work in a part-time capacity because of their enjoyment of the role. The service had a low staff turnover rate of 14%, with low sickness rates of 2% among medical staff and 3% among nursing staff. At the time of our assessment, there were no vacancies or sickness absence among administrative staff.

Agency staff we spoke with had received induction to the service and told us they regularly worked at the service as their preferred temporary employer.

Staff had received and were up to date with appropriate mandatory training. Staff received training on data security and protection; equality, diversity and human rights; fire safety; freedom to speak up; health and safety; infection control; manual handling; PREVENT; and various levels of life support specific to their role. The training was appropriate for the patient group using the service. We saw 100% of administrative staff, 94% of medical staff and 90% of nursing staff had completed mandatory training. We saw that only 75% of medical staff had completed the modules of Fire safety, manual handling, and basic life support, however due to vacancies this equated to one member of staff. We saw plans in place for the member of staff to complete their training. Similarly, we saw not all nursing staff had completed fire safety, basic life support, manual handling and safeguarding children, with these rates being 72%. Due to low staffing numbers this equates to three members of staff. We saw plans in place for these staff to complete their training. Agency staff received mandatory training through their agencies and told us their agency prevented them booking shifts if any required training had not been completed.

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.

All ward areas were visibly clean, had required furnishings and were well-maintained. Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly.

Staff maintained equipment, however it was not always kept clean. During our assessment we observed 6 observation machines that were visibly dirty and dusty and had used thermometer probes in place. These were in all clinical areas of the department including paediatric examination rooms, adult examination rooms, and the observation bay. We found a used urinalysis test on top of a trolley that was used for clinical procedures. The trolley was visibly dirty and dusty. The service had ‘I am clean’ stickers’ available to show that equipment had been cleaned and was ready for use, however these had not been used on any equipment.

Once made aware of the short falls in the cleaning of equipment, the service immediately rectified this, and inspectors found that all equipment had been cleaned to a high standard, and ‘I am clean stickers’ had been used to show staff that the equipment had been cleaned, ready for use. Leaders had added cleaning of equipment to the daily huddle agenda to ensure the issue did not reoccur. and we observed this being discussed.

We observed staff following infection, prevention and control (IPC) principles, including the use of personal protective equipment, effective handwashing and being bare below the elbows. Hand hygiene signage was displayed throughout the UTC. All waste was observed to have been segregated and managed appropriately.

Infection prevention and control training compliance for all staffing groups was 100%.

The service regularly audited hand hygiene and environmental cleanliness and consistently achieved above the 90% target for the trust.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

The service used an electronic prescribing system. Medicines were stored securely in automated dispensing cabinets which were integrated with the electronic prescribing system and patient’s notes. Emergency medicines could be accessed in the event of an emergency. Lockable fridges were available for those drugs needing refrigeration.Processes for monitoring medicines fridge temperatures included automated remote monitoring and local record keeping.Record logs confirmed that fridge and room temperatures were checked daily and were within range.

Staff explained how they ordered medicines and prescription pads (FP10’s) from the hospital pharmacy.We saw prescriptions and controlled drugs were stored securely in the dispensing cabinets and required two members of staff to authorise their removal. Removal of medications and prescriptions were automatically recorded electronically and could be audited by leaders, or remotely by the pharmacy.

The service had systems in place to ensure medicines could be accessed in the event of failure of the automated system.

The service had a process for the supply of medicines To Take Out (TTO) as well as patient group directions (PGDs). PGDs were used by specifically trained staff to prescribe and supply medicines for routine or minor ailments. We saw all PGDs were reviewed in line with the service’s policy. Staff told us they could seek medicines advice from the pharmacy department when needed.

We saw that patient’s allergy status were accurately documented in patient’s notes.

The service undertookquarterly medicines management audits, including controlled drugs, temperature monitoring, and medicines security, and results consistently scored above the trust target of 90%. We saw that any actions needing to be taken were carried out promptly, for example when a member of staff did not know where the override key for the electronic dispensing cabinet was stored.