Ealing Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

At our last assessment we rated this key question as Requires improvement. At this assessment, the rating improved to Good. Care and treatment were delivered in accordance with evidence-based practice. Consent was managed in accordance with legal requirements and staff training.

We looked for evidence that patient and communities had the best possible outcomes because their needs were assessed. We checked patients’ care, support and treatment reflected these needs and any protected equality characteristics, ensuring patient were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

The team had access to the full range of specialists required to meet the needs of patients in the service. Including social workers, pharmacists, speech and language therapists and the frailty team. Divisional meetings included broad representation from allied specialist services, reflecting a collaborative and integrated approach to care.

Policies and guidelines were stored electronically and accessible to all staff. The policies we reviewed were in date and referred to national guidelines. They were based on best practice from the National Institute for Health and Care Excellence (NICE) and the Royal College of Emergency Medicine (RCEM). Staff we spoke with knew how to access policies and were told about updates in newsletters and at team meetings.

Nursing staff showed an awareness of their responsibilities and professional standards of care to which they were required to adhere. Staff were aware of legislation and guidance that protected patient’s rights and knew how to apply this in practice. This included mental capacity and safeguarding.

The previous assessment of the department found issues with the use of CDU and with patient’ case note documentation, where clinicians’ grades were not consistently apparent. These issues were not observed during our visit, demonstrating the actions taken following this previous assessment had been effective.

The triage and time to treat patients for both the ED and UTC were within NHS targets. However, the ED’s was not meeting the four-hour target of 78% of patients being admitted, transferred or discharged within four hours of arrival. The trust was above the local and national average for the four hour target for the last 6 months.

The service did not always work well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

The UTC and the ED operated separately. During our visit, we found that despite the UTC being busy at the front door, this was not supported by the ED team. The ‘Hello nurse’ was part of the UTC team and staffed from the UTC staff complement. We were told, about 50-60% of ‘walk-in’ patients, who self-presented at the main reception, would be seen by the UTC. UTC staff we spoke with described a lack of collaborative working with ED based colleagues. For example, a member of staff said on occasions when they had ‘a queue out of the door’ no one spontaneously came to help from other UEC areas. Although another staff member said that at busy times; after reviewing the UTC lists, help could be sought directly from ED based clinicians, such as the ED consultants but was sometimes dependent on relationships between staff members. We observed that the overall role of the ED nurse in charge did incorporate the UTC, but when the department’s status was described, it focused solely on the ED and did not include an overall update that incorporated the UTC. Therefore, risks across the whole emergency care pathway may not be considered and mitigated.

The senior UEC team explained that the UTC was run by trust-employed GPs and ENPs, worked closely with medical staff from the ED, and both departments asked for advice from each other. We did not observe this close working relationship during our visit. ED staff did not attend the UTC huddle, to gain an oversight of the UEC. When we spoke with ED leaders, there was uncertainty about how all UTC processes worked. There was an SOP that outlined the processes for transferring adult patients as well as unwell patients under the age of 16 round from the UTC to the ED. There were also daily bed meeting at which patient numbers in the ED and UTC were discussed.

The ED was able to stream to the ED same day emergency care (SDEC), if this service could better meet the patient’s needs. The ED SDEC care pathway was managed by the ED team with a senior decision maker at registrar level or above based in this service. We found that the ED and ED SDEC teams worked closely together within an agreed criteria for which patients were likely for same day discharge and should be transferred to this service. Admission criteria included patients over 16 years old, clinically stable in terms of their observations, appropriate for sitting in the clinical area, able to attend to their basic self-care and personal hygiene needs. We were told these criteria allowed teams in this area more time to assess, treat and diagnose. This approach was reported to be beneficial to patients, and these patients were always discharged home from the ED on the same day. The length of time the patient was in both the ED and SDEC was recorded in their EPR.

Patients from the ED could also be transferred to the medical SDEC via a centralised referral system, this service was managed by the acute medicine team. Some ED medical staff we spoke with told us it was ‘difficult’ to refer patients to this area, as it was protocol-driven, had an inflexible admission criteria and patients were often declined. Feedback from ED staff was that they felt the medical SDEC pathway should be made more accessible to the ED team. Enhancing access would not only align with NHS strategic aims of supporting more appropriate alternatives to ED-based care, but also improve patient flow and avoid unnecessary hospital admissions.

The frailty team attended the ED to carry out patient reviews and conduct geriatric assessments (CGAs), providing targeted support as part of their role. We observed this service allowed patients to have an earlier discharge home rather than being admitted to hospital. We found that ED staff were clear on how they accessed this service and were very complimentary about it. The ED and frailty team had clear processes for assessing frailty, which helped identify those patients at most risk from frailty factors and in need of enhanced support from community-based services.

We observed that specialty teams were often in the ED assessing their patients who were awaiting a bed in their service. There were clear responsibilities for these patients who remained under the care of the ED team whilst in the ED. The ED team were responsible for responding to changes to the patient’s physical status, whilst the clinical responsibility for the patient remained with the specialty team. This meant the ED team effectively managed urgent medical needs while the oversight of their speciality needs was provided by the specialty team.

The ED staff told us that the on-site mental health liaison psychiatry completed their own assessment for those patients with mental health needs, based on feedback from ED staff. Staff stated the response for these assessments was swift and they provided ED staff with guidance on the care of the patient’s mental health needs. The psychiatry liaison team also saw other patients in other departments in the hospital and at other trusts, and their input could be delayed if they were in another department or trust. ED staff told us they felt the team could be ‘more visible’ and provide more resources for 1:1 support for patients. When we visited, we saw that patients with mental health needs were experiencing extended lengths of stay. For example, the patient records for the 4 patients with mental health needs that were in ED, showed 3 of these patients had been in the department more than 24 hours, one of whom had been in the department over 65 hours awaiting a bed. The 4th patient had been in the department over 22 hours, awaiting a mental health act assessment after medical investigations had been completed. This delay of obtaining suitable mental health beds is a national issue and the trust were working with partners to identify suitable mental health beds.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Staff used recognised tools to improve the detection and response to clinical deterioration in patients as a key element of patient safety and improving patient outcomes. Staff recorded patient observations using the national early warning score (NEWS) tool for adults and paediatric early warning score (PEWS) for children. The documentation audits for the last 3 months demonstrated that all records reviewed included NEWS and PEWS and that they were correctly calculated and appropriate actions were taken when the NEWS or PEWS was above 5.

There was evidence to show the service routinely monitored patient’s care and treatment to continuously improve it. For example, the use of TES was identified as a risk on the local and trust-wide risk registers following staff feedback regarding safety concerns, and senior managers had made a commitment to reduce the use of this space. However, due to demand on the service this was not always possible. The use of TES was supported by a standard operating procedure (SOP) to inform the safe use of these spaces, this included escalation processes, with exclusion and inclusion criteria to help mitigate risk and ensure patient safety. However, TES areas were not always used in line with the trust’s TES procedure.

Following Royal College of Emergency Medicine (RCEM) audits, the trust had made changes to processes in relation to radiology imaging, which had allowed for more checks and clearer lines of responsibility, sought to avoid prolonged waiting times and reduce disruptions to the radiology registrar’s ability to focus on reporting on the imaging. The new systems had allowed imaging information to be shared centrally, where it was available for daily review by a consultant and appropriate actions taken. Whilst checking the imaging, if there were any clinical concerns or a missed x-ray result the consultant would action this and the patient would be called back to the ED for further review. All missed x-rays would then be fed back to the clinician involved for individual learning and into the wider staff forums for wider departmental learning. The trust provided us with examples of where such discussions had taken place to demonstrate learning. The results of the other RCEM audits had also resulted in improvement work in areas such as sepsis management, trauma imaging oversight, and timely analgesia documentation.

The department ensured patients received care in the most appropriate service and had a range of agreements with local tertiary centres. For example, the ED was not a major trauma centre, to ensure these patients received timely care from the most appropriate service, there was a major trauma transfer process in place that covered all age groups. This supported staff to communicate and transfer the patient to the most appropriate local major trauma centre.

The trust used 2 measures, the Hospital Standardised Mortality Ratio (HSMR) and the Summary Hospital-level Mortality Indicator (SHMI) to monitor mortality rates. The data ending March 2025 demonstrated the mortality indicators remained statistically significantly low for HSMR and similarly, low for the SHMI. There were monthly mortality meetings, open to the whole clinical team where mortality was discussed, and learning identified. The meeting was minuted and the notes shared with staff who could not attend.

The service always told people about their rights around consent and respected these when delivering person-centred care and treatment.

Mandatory training included mental capacity and deprivation of liberty, which included capacity and informed consent. Staff we spoke with were aware of their responsibilities for obtaining consent and the trust’s processes they should follow.

During our visit, the patients we spoke with did not raise concerns regarding their consent to treatment. Staff facilitated patients to make their own decisions. During triage consent was gained and recorded in their patient record.

Some staff in the department wore body camera’s, which had been introduced to reduce violence against staff. We were told the staff would inform patients and complete an electronic incident record whenever they turned on body camera technology. CCTV was observed, and we were informed that this was monitored by security staff. However, not all CCTV signage was clearly visible in all areas. For example, signage within one of the designated mental health rooms was not clear, and patients may not have known they were being monitored and images recorded within this space.