Ealing 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

At our last assessment, we rated this key question as ‘Good’. At this assessment, the rating was ‘requires improvement’.

The service did not always work with people to understand and manage risks by thinking holistically. The service did not always make sure there were enough qualified, skilled and experienced staff. The service did not always assess or manage the risk of infection. The service had a good learning culture and people could raise concerns. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

This service scored 59 (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 used an electronic system all staff could access, and staff told us this was easy to do and were clear about the type of incidents which should be reported. The data we reviewed showed that the service was reporting a range of incidents including no harm incidents and those that had resulted in severe harm. On average the division reported around 700-800 incidents per month with around 93% of these incidents being categorised as low or no harm. Data showed that 92% of incidents reported by ED and 90% reported by UTC were categorised as low or no harm.

Staff who had reported an incident could request individual feedback once the investigation was completed. However, leaders did not know how frequently this option had been used. There was a no blame approach to reporting incidents, which empowered staff to report any issues without fear of negative consequences. Staff felt lessons were learned from patient safety incidents and changes were made to reduce risks. They understood their responsibilities relating to duty of candour and when this should be applied. They knew this involved an apology to those affected as well as an investigation into certain adverse events.

There were multiple channels for sharing lessons learned, including ED communications such as newsletters, visual feedback on incidents displayed on staff notice boards, and discussions during daily safety huddles.

There were systems in place for staff to access debriefs after incidents. This included verbal debriefs for those involved, end of shift briefings and individual supervision. The senior staff we spoke with said these were helpful for staff learning and development.

When appropriate the department participated in multidisciplinary investigation. For example following a patient safety incident the department along with the acute medical unit (AMU), the area the patient was transferred to and other partners, completed a multidisciplinary investigation, learning and areas for improvement were identified and an action plan developed. For example ED and AMU staff along with staff from two neighbouring mental health trusts worked together to develop a new physical restraint policy that had been implemented in the ED and other clinical areas.

The service did not always work with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They did not always make sure there was continuity of care, including when people moved between different services.

Urgent and Emergency Care (UEC) services had been reconfigured, there was now one booking in and patient streaming service for both the ED and the UTC. Patients and their families were greeted by the ‘Hello Nurse’ at the main entrance, serving as the ‘front door’ to UEC services. This approach was taken during peak times, 10am to 10pm, to facilitate flow through the department. Outside these hours an UTC emergency nurse practitioner (ENP) covered this role. This role was introduced to ensure patients were greeted, assessed and treated in a timely manner based on their clinical needs. This may be to the UTC or ED, or in some cases directly to the clinical decisions Unit (CDU), rapid access treatment (RAT), or same day emergency care (SDEC) service. There was clear guidance on what injuries were directed to which department for example fractures that needed manipulation under sedation would be directed to ED, while fractures that required no manipulation would be treated in the UTC.

There were 2 separate SDEC care pathways. The ED SDEC, which was run as part of the ED, required a clinician-to-clinician discussion before patients were transferred from other areas of the UEC service. When patients were referred to Same Day Emergency Care (SDEC), which was managed by the Emergency Department (ED), their time in the department continues to be recorded on the Electronic Patient Record (EPR). However, these patients are not included in the 4-hour ED target. This was consistent with Emergency Care Data Set reporting guidance

The medical SDEC pathway required a referral and agreement between the ED team and the acute medical team before patients could be transferred there. Staff we spoke with said they found the medical SDEC difficult to access, calling it ‘process-driven’, because of the referral processes, and stated patients were often declined. This impacted on the flow through the department and on patient waiting times.

The trust had a full capacity protocol (FCP), to assist in the management of overcrowding in the ED. Senior leaders acknowledged that the department had to adapt and operate differently in these situations to manage the risk and ensure patient safety. The FCP included the criteria for activating the protocol, actions to be taken including the escalation processes. This facilitated patients receiving timely and appropriate treatment and improve patient flow by using all available resources effectively. The trust does not collect data on the number of times the Full Capacity Protocol is enacted. However, the enactment of the full capacity protocol was reported in the 4 times daily site situational report.

The service had a standard operating procedure (SOP) for patients cared for in temporary escalation (TES) areas. However, the policy was not always adhered to. All ambulances accessed the ED via a separate entrance and were handed over to either a nurse or a member of the medical staff who staffed the ‘pit stop’ area. When this area was full, patients were held in a Temporary Escalation Space (TES) areas including the ‘cohort’, a 5-bedded curtained area, in the corridor, and when these areas were full, patients were held in the back of an ambulance. Handover to the ED staff was not always undertaken in a timely manner. We observed that some ambulance crews were kept waiting despite no patients being in the RAT area. The receiving RAT nurse when they returned to the desk, did not acknowledge the paramedic, who had been waiting over 15 minutes, and were about to leave the area without completing the handover, until they were challenged, whereby the nurse then took the handover. This meant that transition between services was not always undertaken in a timely manner and was not in line with the trust’s temporary escalation space (TES) procedure.

There were specific designated waiting areas for ED, UTC and a separate paediatric waiting room. The paediatric waiting room was not restricted access, and we observed other patients accessing this area. The waiting rooms were visible to staff based in these areas, including main reception staff and the security guard. We were told safety rounds, had been introduced and took place 6 times a day, to mitigate the risk of patients that might deteriorate in the waiting room. However, patients were not routinely given updates on likely waiting times. Data demonstrated that 96.3% of patients were triaged within 15-minutes, and 93% of patients were seen by a clinician within 1 hour of arrival, this was in line with national standards.

At the time of our visit, on the 15th July 2025 64.3%, and 64.9% on the 16th July 2025 of patients spent less than 4 hours in the UEC. This was below the national performance target of 78%. ED and UTC performance was reported via the department’s performance reports, the internal daily BI performance tracking email, and at the daily operational 0945 meeting where performance was reviewed. Performance was also tracked and improvements identified at the trust-level flow board and reported to the trust board monthly.

The ED did not provide a paediatric ED service. There was signage that the ED did not treat children. However, if a child arrived and needed urgent care or resuscitation, the nursing and specific medical staff were suitably trained to provide emergency treatment and stabilise the child, before they were transferred, in line with the trust’s paediatric transfer policy, to a suitable paediatric ED. An incident form was completed for children arriving at ED to record numbers and the outcome for the child. Children were seen in UTC. We were told the emergency Practitioners (EPs) in UTC had completed advanced training in the assessment and management of paediatric patients presenting with minor injuries and minor illnesses. We saw the content of this course but were not provided with the percentage of EPs who had completed it.

The hospital did not have a hyper-acute stroke unit, (HASU) all patients presenting at the ED who had had a stroke were transferred to the HASU to Northwick Park hospital. There was a standard operating procedure for these patient transfers that provided guidance on who to transfer. The trust does not collect data on the number of HASU transfers from Ealing ED to Northwick Park ED. A previous snapshot audit undertaken in 2022 and 2024 demonstrated that there were on average 10 referrals per week in 2022 and 9 referrals per week in 2024.

Imaging facilities, such as MRI, CT and x-ray were located close to the ED. There were protected ultrasound slots for ED, out of hours there was limited access to MRI and no facilities at weekends. To ensure there was access to MRI for patients with time sensitive conditions through collaborative working and agreed transfer policies with the Northwick Park site as well as with a neighbouring NHS trust. There was a clear process for oversight of imaging, a named consultant was responsible for ordering and reviewing imaging. The report of the results from the patient imaging, were added to the patient’s records. All records were on a unified electronic patient record (EPR) which meant access to patient records was available in both ED and UTC. The trust submitted evidence of how incidents involving imaging errors, such as undetected fractures, were reviewed and used for staff learning, to reduce the risk of similar incidents occurring.

To improve patient privacy in the ‘cohort’ TES area, we were told by senior staff that curtains had been fitted, which acted as partitions for improved patient privacy. However, there were no screens to provide privacy when patients were cared for in corridors. Patient safety risks in this area were not always mitigated. For example, during our visit, we observed a patient in the cohort bay at 18:45 hours, despite there being suitable space for this patient, available in staffed areas of the ED, such as 2 empty bays in ED ‘Pitstop’. No nursing staff were present in the cohort area when we arrived and the patient was alone without relatives, for at least 15 minutes with the doors to the cohort area closed, as were the doors in the nearby pitstop. This was not in line with the trust’s TES procedure, that states patients in TES areas must be in the line of sight of nursing staff. The patient did not have access to a call bell, or other means of summoning staff for help apart from raising their voice or making a loud noise. The patient’s notes indicated they had come in with chest pain and had a known learning disability with epilepsy. The patient had had some clinical observations recorded and had had an ECG, which showed some minor changes. During our visit, we raised this issue with the provider, but by this stage, the patient had been moved to CDU prior to discharge home.

There was a clear pathway for patients with mental health concerns, which had been developed in partnership with colleagues from a mental health trust. Where a patient needed help for a mental health crisis, a triage nurse would be assigned to them urgently to assess their needs. We were told all triage nurses had received appropriate training for this role. Staff would then request the psychiatric liaison team to attend the department to carry out a mental health assessment and risk assessment. All staff we spoke with could describe the pathway for mental health patients, including risk assessment and management.

Whilst mental health patients were initially assessed and triaged in a timely manner they could experience long waits for a transfer to specialist mental health services. We noted in the period May to July 2025, 80-82% of patients waiting for a psychiatric review were seen within the priority time of 1 hour, this was below the national target of 95%. Psychiatric liaison staff members were involved in ED care plans to outline how patients should be cared for to meet their individual needs whilst in the ED. Mental health assessment and monitoring documentation was not always completed. The randomised documentation audit undertaken by the trust for June and July 2025, showed mental health assessment forms were completed in 90% of case notes in June 2025 but this reduced to 80% in July 2025. The behavioural charts were completed for 80% of case notes in June 2025 and 90% in July 2025. The department’s expected compliance rate for these measures was 90%. To support this the trust was in the process of recruiting to a Lead Mental Health nurse for the ED who will have a focus on improving compliance with mental health related documentation.

The service had a patient flow lead coordinator for all patients using the UEC service. Their role was to ensure that UEC patient lists flowed through the correct care pathway for their needs. This meant patients were directed to the most appropriate clinical care pathways for their needs, supported flow through the department and improved ED performance.

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. However, not all staff were compliant with the required level of safeguarding training.

Staff we spoke with could describe how and when they would raise a safeguarding concern and access the safeguarding policy and protocols. The staff in the ED demonstrated a good understanding of safeguarding including who to contact, how to complete referrals and how to take appropriate and immediate action when needed. In the 12 months July 2024 to June 2025 the department made 408 adult safeguarding referrals and 331 children’s referrals, showing staff knew how to recognise and report abuse.

Staff received training in adults’ and children’s safeguarding as part of their mandatory training; the level of training was dependent upon their role. At the time of the inspection, data showed that over 94% of ED medical staff and 100% of UTC medical staff had completed their safeguarding training, which was above the trust target of 90%. Not all other staff groups had met the 90% target. ED nursing staff had met the target for safeguarding adults’ level 3, 92% had completed this training. However, for children’s level 3 training, 85.5% were compliant. The UTC nursing staff did not meet the target for safeguarding adults’ level 3, 75% were compliant or for children’s level 3 training, 80% were compliant. All administration staff had met the target for safeguarding adults’ level 2, 100% and children’s level 3 training, 100%.

The divisional director of nursing chaired a monthly mandatory training meeting with the area leads to review training compliance and explore what was being done to improve compliance rates. It was acknowledged that some gaps in compliance were down to staff on long term sick leave and availability of training. An internal mandatory training tracker was used by senior staff to record communication with non-compliant staff and included dates for future training. This meeting validated and challenged the data entry to ensure the online platform was being updated correctly having previously identified an error with the learning platform.

Leaders and staff in the ED told us that staff undertaking streaming and triage at the front door to the UEC services always had safeguarding on their radar, remaining alert to any potential signs of abuse or neglect. Senior ED staff told us the trust safeguarding team were ‘extremely responsive’, making direct contact with UEC staff teams in a timely manner when referrals had been made or queries raised. However, not all staff undertaking streaming and triage were compliant with safeguarding training.

The service did not always work with people to understand and manage risks by thinking holistically. 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.

The service did not always understand or manage risk well. In our review of patient records, we saw frequent gaps in the recording of patients’ pressure areas. Monthly documentation audits showed that skin assessments were not consistently completed, with the worst performing months so far this year, were March 2025 showing 56.7% of eligible patients had a skin assessment completed and May 2025, showing only 26.7% of eligible patients had a skin assessment completed. This was a known issue and was discussed at the divisional quality and risk meeting. We were told there were plans to address this, including discussing the importance of documentation in nursing handovers, more frequent audits to monitor the trend closely, and encouraging staff to share information on the challenges they faced in completing documentation. We were told there was no specific ED action plan to address these issue as they participated in the trust-wide prevention and management of pressure ulcers programme to improve care in this area. Information provided by the trust did show improvements for June 2025, where 78.3% of eligible patients had a skin assessment completed and July 2025 showing 86.7% skin assessment completed.

The psychiatric liaison team was based on-site at the hospital and responded to referrals from the ED to assess mental health patients. This team was available 24 hours a day, 7 days a week. There was a pilot planned to have a member of the liaison team based in a room in the ED at all times, and the staff we spoke with welcomed this initiative. At the time of our assessment this initiative had not yet commenced.

ED staff told us they were aware of the procedures and mitigations in place to keep mental health patients and staff safe in the ED, but there were times when staff did not feel safe, due to a lack of skills and knowledge. Specific mental health-related policies had been developed, and mental health training had been made available to staff. We were also told there was dedicated daily support from a mental health nurse. As these improvements had only recently been implemented, their impact had not yet been seen.

Whilst waiting for ED and UTC triage, patients seated in the waiting areas were visible to staff, including main reception staff and the security guard, and staff passing in and out of this area. To mitigate the risk of deteriorating patients not being identified in a timely manner, the trust had introduced 6 daily waiting room checks.

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

All areas visited were visibly clean, but not all were well-maintained. For example we saw an isolated example of chair seats being torn. We were told these were due to be removed on the day of our visit. There were also areas of damage to the flooring observed within the main ED clinical area, which presented a potential trip hazard, we were informed that these were due to be repaired, but staff were not able to give a timescale when this would be completed.

There were specific designated waiting areas at the main front door for ED, UTC, and a children’s waiting room within the same area. This caused confusion for patients as these waiting areas were not clearly defined, and the patients we spoke with were unclear which service, ED or UTC, they were waiting for, and exactly which parts of the service were managing their care. The paediatric waiting room was not restricted access. We observed other patients accessing this area. Therefore, we could not be assured children were safe while in this area and unauthorised people could easily access the area.

The ED had several ligature points which were a risk to mental health patients. The risks were managed through risk assessments, management plans, observations and use of ligature light rooms, when available. The trust were aware of this risk, and this was highlighted on the trust risk register. The ED had recognised the need for safer, ligature light spaces to safely support patients in a mental health crisis. There were two ligature light rooms available, one with a ligature light en-suite. Staff from the health and safety team of a neighbouring mental health trust were involved in environmental reviews of the ED and liaised with and advised staff at the trust. This approach ensured risks were identified and mitigation implemented.

There was no ligature-light communal bathroom available for patients. When the ligature light en-suite bathroom was occupied, mental health patients had access to a bathroom opposite the nursing office. This had several ligature anchor points. To mitigate this risk, staff said they would accompany the patient into the bathroom; while this may compromise patient dignity, this was considered against the level of risk. However, we could not see an assessment or plan in the patient’s records to identify if this supervision when using the bathroom was required. This meant there was a risk that a patient could have access to a room with ligature anchor points without appropriate supervision. We were told the trust’s health and safety team were meeting in July 2025 to discuss this matter.

The department had several resuscitation trolleys; however, the TES areas did not have a resuscitation trolley. A risk assessment had been undertaken, and cardiac arrest trolleys were located in the department so that they could be accessed within 30 to 40 seconds from all areas that they cover. The logs of the resuscitation trolleys we reviewed showed they were checked daily by staff and signed off as being appropriately stocked.

The ED had considered its layout in relation to the security and safety of mental health patients. For example the department had moved an area used for mental health patients, as this had been close to an exit door.

We observed that all handovers were undertaken in a designated area where patient confidentiality could be maintained.

The service did not always make sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Senior nursing staff told us the trust used the Royal College of Nursing (RCN) staffing model for ED of 1 nurse to 4 patients. External consultants had recently reviewed nurse staffing and had recommended appropriate nurse staff numbers for each shift. This included staff cover for the shift lead role, triage, ‘pit stop/ ambulatory, resuscitation, majors, patients who self-presented, the clinical decision unit and the ED SDEC. There were no funded posts for the TES area. However, the daily staffing model included the TES area. Additional bank shifts were added to the rota to have additional support for the TES areas. The department had a TES procedure which stated a ratio of 1 nurse to 5 patients, this was in line with NHS safer staff recommendations. At busy times this ratio was not achieved, therefore the TES areas were not always safely staffed in line with the trust’s policy and placed patients at risk of harm.

At the time of our inspection, nursing vacancies were 8.9%, this had improved over the past 12 months from a previous vacancy rate of 24.7%, in July 2024. We noted in June 2025 that for nursing staff the turnover was 2.1% and the sickness level was 7.13%, which was above the national average of 5.4%, for nurses’ sickness. Vacancies and sickness was covered by bank staff to ensure the department had appropriate staffing levels.

There was a matron for ED, and appropriate cover for this post by the trust’s UEC head nurse. There was an identified lead nurse assigned for each shift, who provided local leadership. Each area in the ED had specific staff allocated that had the appropriate skills and experience. For example, the resuscitation area was staffed by 2 qualified, experienced nurses, who had the skills and knowledge to deliver care to this group of patients.

All nursing staff worked 12.5-hour shifts, it had been identified that between 14.00 and 22.00, more staff were required. To cover this period a twilight shift had been introduced. Gaps in rotas were filled using bank staff in line with the trust’s safer staffing and escalation policy. We noted bank staff at times exceeded 20% per shift, potentially meaning staff may be unfamiliar with the environment but this was mitigated by the ED’s own staff often filling these bank shifts.

The Royal College of Emergency Medicine (RCEM) suggests 1 consultant per 4000 annual attendances. Based on the number of patients attending ED over the last 12 months, using this ratio it suggests the department should have 10.85 consultants. However, this is guidance, and the complexity of the patients and department size needed to be considered. The department was not a major trauma centre; therefore, the ratio of consultants had taken this into account when identifying the medical staffing establishment. The department did not meet this recommendation as the ED had a medical staff vacancy rate in June 2025 of 26.2%. The medical staff in the department had a sickness rate of 3.32% in April 25, which was above the national average of 1.6%. We were told ED consultants, and locally employed doctors (LEDs), predominantly at registrar level, usually worked cross-site. This approach provided resilience and ensured there were always 2 consultants present in the ED, one lead consultant who remained in majors, supported by a staff grade doctor and another who oversaw the CDU and RAU/ED SDEC. The doctors we spoke with described the ED consultants as being very approachable, accessible, and supportive. However, some of the junior doctors reported that some of the registrars were less approachable than the consultants when they had queries and concerns.

There was a dedicated mental health nurse on duty in the ED between 7 am and 7 pm, 7 days a week. We were told by the ED staff that they would routinely cover the mental health nurse for breaks, complete close observations of mental health patients, deliver care for these patients.

Staff described a rise in the number of mental health patients accessing the ED and the mental health liaison team stated they had seen a steady rise in their referral numbers. During our visit, we saw mental health patients who required certain levels of observations. For example, constant observation from a staff member with eyesight of the patient. Staff confirmed that there were times when there were more patients needing observations than staff available to provide it and would cohort these patients so one member of staff could observe more than one patient. The trust had recognised that there was pressure in meeting the level of mental health observations required in the ED and was in the process of developing several workstreams to improve this. They were also putting in place initiatives to encourage and support improved integration between ED staff and the mental health liaison team. For example, from August 2025, the liaison team manager would be attending the emergency department monthly team meeting. The mental health liaison team had delivered several training sessions to ED team leaders to develop their knowledge and assist in meeting the needs of this group of patients.

The UTC and ED were staffed separately. The UTC was led by General Practitioners (GPs) and Emergency Nurse Practitioners (ENPs), both employed by the trust and operated 24 hours a day, 7 days a week. Between 10 am and 6 pm, there was a UTC ‘Hello nurse’ based at the entrance to the UEC, who triaged patients at the front door. We were told this role was carried out by ENP’s. Outside of the Hello Nurse hours, we observed that the Hello nurse not only directed patients to the correct area, but also triaged, took observations and escorted patients to other specific areas. This meant the front door was not always covered by staff, and triage was delayed during their absence, resulting in increased waiting times. The ED team did not routinely flex and assist the UTC triage nurse when queues were developing or when the UTC nurse needed to leave their position. The ‘Hello Nurse’ initiative was aimed at improving flow and patient experience but at times resulted in delays in patients booking in, patient frustrations and potential risk of missing critically unwell patients. Staff told us the scope of the Hello nurse was too wide, and that the role should be staffed in addition to UTC staffing numbers. We were told by staff there was no specific training for the UTC "Hello nurse" for this streaming role. Following our inspection, we were told all registered nurses undertaking the ‘Hello nurse’ role had completed specific competencies related to the streaming guidelines. There was guidance on which patients should be directed to ED and which ones went to UTC. This facilitated patients being seen in the most appropriate area. Following our inspection the trust stated that the ‘Hello’ nurse project had been evaluated. However, the evidence provided did not provide assurance that the project had formally been evaluated.

On the day of our visit, the UTC had 3 GPs and 3 ENPs on duty. The team was supported by a HCA who did the more routine tests, like ECGs, urine tests etc and by dedicated UTC reception staff who clerked patients at the main reception desk. The UTC team held a huddle at 10am to discuss a range of issues, including staffing, number of patients in the department, and the number of ‘breeches’, where patients had been in the department for longer than the 4-hour target. The ED and UTC staff both attend the daily divisional Sitrep meeting where issues such as staffing were discussed, escalated and an action plan developed

The trust recognised the importance of having safe systems in place around physical intervention. We were told the security staff, employed by a private provider, were trained in physical intervention and would support the ED staff if this intervention was required. Training was also planned for ED staff in physical intervention, as this had been recognised as being required to develop safe care to patients. A safety pod, which aimed to minimise the need for physical restraint, reduce injuries, and support de-escalation techniques had recently been purchased.

Staff had access to training and supervision. The service was compliant with mandatory training and appraisals. In UTC, 100% medical and administrative staff had completed their mandatory training. In ED 93.75% of nursing staff,97.62% of medical staff and 96.13% of administrative staff had completed their mandatory training. The ED medical staff appraisal rate as of July 2025 was 94%.

Medical staff had access to additional training. For example, all ED consultants, registrars who were in charge of the department and specialty trained doctors had completed Adult Life support (ALS), 54% had completed Advanced Trauma Life Support (ATLS) and 91% had completed European Paediatric Advanced Life Support (EPALS). We were not provided with information about how the numbers of medical staff who had completed ATLS would be increased. Following our inspection the trust stated that the lead registrars in ED, working at night in the senior decision maker role, must have ATLS. If they did not they were moved to a non-lead shift until they were compliant.

Children were not seen in ED but were seen in UTC. We were told the Emergency Practitioners (EPs) in UTC had completed advanced training in the assessment and management of paediatric patients presenting with minor injuries and minor illnesses. Nursing staff also had access to additional training. Data provided showed 71.42% of band 6 nurses and 66.60%. of band 7 nurses had completed paediatric Immediate Life Support (PILS) training. Compliance figures for immediate Life Support (ILS) training showed 88% of band 6 and 77.80% of band 7 nurses had completed this training. We were told that due to training capacity and clinical need, band 5 and below nursing staff did not routinely receive paediatric training and this training had been prioritised for band 6 and above nurses. ENPs triaged children under the age of 16 in the UTC. Following our inspection, we were told ENPs had completed an advanced training qualification in the assessment and management of paediatric patients presenting with minor injuries and minor illnesses, which includes triage. However, we were not provided with the percentage of staff who had completed this training.

The practice development nurses (PDNs) supported the service, taking an active role in managing the education programmes for nursing at various levels. Their programme of learning was based on a needs analysis. Staff we spoke with stated they were unable to increase the number of courses provided due to capacity.

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

During our visit to the ED, we observed clearly marked bins for waste segregation and sharps disposal across areas such as RAT and CDU, where all sharps’ bins were closed, dated, and signed. Linen skips were used appropriately and regularly emptied. The department was generally tidy, with clean floors and with most areas maintained. However, there was an area in the department where the flooring was cracked presenting an infection control risk as it may not be able to be cleaned effectively. We were told work was planned to address this but not provided with a timescale for completion of this work. Equipment was not consistently cleaned and labelled as clean after use. Therefore, it was not possible for staff to identify that equipment had been cleaned and was ready for use. Cleaning staff were frequently visible, although cleaning schedules were not consistently displayed, for example, public toilets in the UTC and CDU lacked signage indicating when they were last cleaned or next due for cleaning.

To reduce cross-infection, there were isolation rooms available and in use for infectious patients. However, these were not always used in line with best practice to effectively manage the risk of cross infection. For example, a patient with an isolation sign on the door to their room and documentation identifying an infection control issue had the door to their side room left open. We observed staff did not use appropriate Personal Protective Equipment (PPE) to enter the room or close the door, to mitigate the risk of cross infection.

PPE, including gloves, masks and aprons, were available inside side rooms in line with trust policy. We observed a patient who attended ED by ambulance with query an infectious respiratory disease, at 8.21pm not isolated until 3.41am, the next morning. At which point the patient was placed in a side room with the appropriate respiratory isolation signage on the door and the door kept closed.

There were missed opportunities for enhanced IPC screening at the front door of the UEC. Staff did not ask patients attending the UEC about IPC risks or about recent travel, during their assessments. We noted that numerous staff wore wrist watches and hand washing did not always take place in between patient’s care, or when staff left and/or entered a clinical area. When these issues were raised with staff during our visit, senior staff told us that infection protection and control (IPC) lapses could not be attributed to a lack of knowledge, as all staff received IPC training. The senior staff told us IPC issues could be attributed to staff ‘burnout’. Where the constant and high flow of patients within the ED could have contributed to the staff lapses observed, in maintaining more optimal IPC standards. The recent staff survey showed 44.2% of staff reported they often felt tired, 35% reported they felt a ‘high degree’ of burnout and 39.2% reported they always felt worn out at the end of their working day. Infection prevention and control data was shared at the divisional quality and risk meeting. For example, in April 2025 the hand washing audit reported 90.7% of staff were compliant with hand washing. This high level of compliance did not support our findings during our visit. And MRSA screening compliance was 84.7%.

Following our visit, the service reported several measures introduced to strengthen infection prevention and control (IPC). These included IPC team 'spot checks', daily walkarounds by senior ED staff, and plans for a more systematic use of checklists to help maintain high IPC standards. Regular IPC reminders were being shared through ED communications. As this action had been taken following our visit we were unable to assess the impact.

Staff used the sepsis 6 bundle and the records we reviewed showed that most patients with suspected sepsis, were assessed and treatment provided within an hour. This meant by providing rapid treatment, it improved their chances of survival.

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 had safe systems in place for the appropriate and safe handling of medicines. Medicines were managed in line with best practice and national guidance. Staff told us they had access to local medicines’ policies, procedures, and guidelines. The policies we saw were up to date and in line with best practice.

Medicines were stored securely in line with national guidance and only accessible to trained staff. Emergency medicines could be accessed in the event of an emergency, meaning patients received medication in a timely manner. Medical gases for example, oxygen cylinders, were stored securely in line with best practice. We noted empty cylinders were kept separately ready for collection and which reduced the risk of failure to provide essential respiratory support to patients.

Medicines, including controlled drugs, were disposed of safely when no longer required and suitable records kept. Records of controlled drugs handling were accurate and made in line with legislation, best practice and local policies.

The service used an electronic prescribing system, and we noted that all medicines were also recorded on the electronic patient record. Medicines were administered as prescribed, following national guidance and local policies. We observed all medicine omissions, for example, if the patient was asleep, the medicine was out of stock, or the medicine was refused, were clearly documented on the patient’s electronic record. This ensured there was a clear record of what had been prescribed and what had been administered.

Staff we spoke with told us they had received specific training in the management and administration of medicines. Only those staff assessed as competent to administer medicines to patients undertook this task.

The patients we spoke with told us they were given information about their medicines, especially when there were changes to their medicines. This was provided in both written and verbal information, providing an opportunity for patients to ask the ED and pharmacy staff any questions about their medication. Allergies were recorded in patient records, and they were given coloured wrist bands to wear, indicating to staff that they had an allergy. The department had prepared ‘to take away’ (TTA) packs of medication which could be given to the patients to avoid delays in discharge.

Staff had access to pharmacy support, including an out of hours on call pharmacy support service, pharmacy team and the trust’s Medication Safety Officer (MSO). Staff we spoke with stated that the pharmacy team were responsive to queries staff may have.

Regular medicines management audits were carried out, which included medicines reconciliation, missed and delayed doses, and compliance with relevant patient safety alerts. Quarterly controlled drug audits were completed and any areas for improvement identified.

Staff we spoke with knew how to report any medicine incident and that these incidents were discussed regularly at departmental meetings and learning shared. For example, in response to an incident the trust had developed and implemented a protocol for the use of rapid tranquilisation in the department. This included the requirement for hourly physical health monitoring, such as consciousness, pulse, blood pressure, rate of respiration, after the administration of rapid tranquilisation. However, the patient record for a patient who had received rapid tranquilisation, did not include evidence that their physical health had been monitored in line with the trust’s protocol. This placed the patient at risk of timely intervention not being provided in the event their physical health deteriorated.