Bradford Royal Infirmary

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 meant we looked for evidence that people were protected from abuse and avoidable harm. 

We assessed 8 quality statements. We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected when this was in their best interests and in line with legislation.

At our last assessment we rated this key question Good. At this assessment the rating has changed to Requires Improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed but we saw improvements being made in response to our daily inspection feedback . The service had a good learning culture and people could raise concerns. Managers investigated incidents and people were protected and kept safe. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that.

The service was in breach of the legal regulations in relation to safe care and treatment, staffing, premises and equipment.

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.

We scored the service as 3. The evidence showed a good standard. 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. We scored the service

The department had clear processes to report incidents and learn from incidents and near misses. Staff briefings took place at the beginning of each shift to cascade any learning to staff that they needed to be aware of. Staff told us they had received training to use the incident reporting system, although 2 staff members said they had not received formal training but understood how to use the system. All recognised the importance of reporting incidents, but some said it patient care priorities took priority over reporting incidents. We reviewed patient safety incidents reported by the urgent and emergency care department (ED) between September 2024 and August 2025 and found that staff had reported 2,601 incidents. Recurrent themes included 5 patient falls.

Governance and safety meetings supported learning from incidents. Incident and events were discussed at daily safety huddles.

The trust had a post-incident support process to support staff following high-impact events. This included ‘hot debriefs’ immediately after an event and a planned follow up ‘reflect and refresh’ session offered to all staff 1-2 weeks after the event (known as ‘cold debriefs’). Trust leaders advised all staff were invited to both sessions. However, some staff reported “cold debriefs” did not always happen, or if they did, they were not always included.

Staff told us safety huddles happened at least daily. They discussed the department’s status, risks and shared learning from incidents and any feedback received. During our inspection we observed safety huddles and saw feedback being passed to staff. On one occasion, staff were reminded to store cleaning chemicals safely. However, later that day, we saw that chemicals had not been stored safely.

We reviewed patient safety meeting records, bulletins, newsletters and posters used to inform staff about recent incidents in the department. Staff also received regular emails with specific information or reminders about changes to standard operating procedures, including when procedures were not being followed correctly. These reminders supported learning.

The trust had a Being Open and Duty of Candour policy, which was due for review in November 2026. The policy explained staff roles and responsibilities, how to define levels of harm and the actions required when an incident met Duty of Candour requirements.

Staff told us they understood their responsibilities under Duty of Candour, including being open and honest and offering an explanation when something went wrong. Duty of Candour training was part of the induction and included in other training modules.

We scored the service as 2. The evidence showed some shortfalls. 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.

When patients arrived at the emergency department, reception staff booked in people who self‑attended and passed their details to a senior nurse. The nurse reviewed and triaged patients and allocated them to the most appropriate area.

Patients who were directed or “streamed” to the emergency department were triaged by trained staff using the Manchester Triage System (MTS). A senior doctor or clinician was available to assess patients and refer them directly to clinical specialties. Staff told us there were pathways to stream patients straight to specialty assessment areas in the hospital. Nursing assistants carried out initial tests, such as blood tests and ECGs, in preparation for medical review.

The national target for triage was 15 minutes. Bradford recorded an average triage time of 16 minutes in March 2025, which had improved from 23 minutes in December 2024. At the time of our visit, a same day emergency care (SDEC) area had been created on a ward above the ED and was open from 8am to 8pm daily as part of a 4‑week trial. Staff were keen to extend this trial. Senior medical staff worked in the SDEC area and treated patients quickly and effectively. Staff told us it helped reduce pressure on the main department and supported timely care. Patients gave positive feedback about the environment and shorter waiting times. Staff could also book follow‑up SDEC appointments directly.

Reluctance from some specialty doctors to review patients in ED contributed to poor flow. RCEM professional standards state that specialty doctors should review patients within 60 minutes of a request. Some specialties were supportive and had a regular presence in ED, but others refused to attend or said they would only review patients once moved to the acute medical unit (AMU). This caused delays to patient reviews, potential delays to treatment and care planning, and overcrowding in ED because the AMU often had no beds available to transfer patients to. Medical staff in the ED told us they were frustrated because of the impact this had on patients and the department and because it left them unsupported by some specialties. We were concerned that delays meant patients might not receive the right treatment at the right time, increasing the risk of harm or incorrect care and treatment. This was a breach of safe care and treatment.

Further, patients often experienced long waits before being moved to wards. During our inspection we saw patients waiting in ED for over 24 hours. We also saw examples of patients completing their treatment in ED and being discharged home from the department because they had not been moved to a ward due to lack of beds. Hospital‑wide discharge delays affected the flow of patients through the ED. Poor patient flow impacted patient experience and safety. These experiences were reflective of the national picture in terms of concern demand and flow through emergency departments.

The ambulance handover area had 3 bays with patient trolleys and a “fit to sit” area with 6 reclining chairs. Nurses and health care assistants oversaw both areas. After handover and initial assessment, staff could request and carry out tests such as blood tests and ECGs in preparation for review by a doctor. This was a busy area and we saw patients waiting on trolleys waiting to be handed over to nursing staff. The department was introducing the new National Transfer of Care standard operating procedure (SOP). This required ambulance crews to hand over patients after a 45‑minute wait and leave the department, to improve ambulance availability and response to 999 calls. Ambulance crews gave positive feedback about staff support and the time taken to hand over patients.

Between October 2024 and September 2025 an average of 100 ambulances arrived at the department each day. The average handover time improved from 27 minutes in November 2024 to 18 minutes in September 2025. This remained slightly worse than the national 15‑minute target.

Although the department was busy during our inspection, we did not see patients left unattended or receiving clinical care in the corridor. Staff told us corridor care was never accepted and worked not to leave patients waiting there.

Leaders met throughout the day to discuss patient flow, including risks related to ambulance waits and long waits in ED. These systems ensured leaders at all levels were aware of performance and risk. We observed one of these meetings and saw teams working together to free beds and anticipate upcoming discharges and potential bottlenecks. Teams worked in unison to improve patient flow.

Allied health professionals (AHPs), including physiotherapists and occupational therapists, supported patients in the department and carried out predischarge assessments when needed.

Electronic discharge summaries were completed for patients discharged home. These included all relevant information from their stay in the department.

We scored the service as 2. The evidence showed some shortfalls in the way patients were safeguarded. The service worked well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. However, not all staff were trained to the right level of safeguarding qualifications.

In April 2025 the trust reviewed the level of safeguarding training to be undertaken for all roles at the trust. This resulted in more staff requiring safeguarding training and as a result compliance levels dropped as more staff required training at the various levels. A comprehensive education plan was in place at the time of assessment and further safeguarding training was available to staff to increase compliance. Training compliance for staff working in the ED department was as follows:

• Level 2 adults safeguarding training, medical and dental staff were 75% compliant, while nursing staff, allied health professionals (AHPs) and other clinical staff were over the trust's 90% compliance rate. Medical and dental staff were 75% compliant.
• Level 1 childrens safeguarding training all staff groups were over the trust's 90% compliance rate.
• Level 2 childrens safeguarding administrative and clerical staff and medical and dental staff did not meet the trust's 90% compliance rate.
• Level 3 childrens safeguarding medical and dental staff and nursing and midwifery staff did not meet the trust's 90% compliance rate.

Security staff were often called to support colleagues caring for people who were vulnerable, including people living with dementia or delirium, and those experiencing a mental health crisis. Security staff had completed de‑escalation and restraint training to make sure they could safely manage distressed, aggressive or violent patients and visitors. Each restraint event was recorded as an incident. We observed security staff supporting several distressed or aggressive patients during our inspection.

Security staff did not complete routine safeguarding adults or safeguarding children training. The trust’s policy stated that security staff should not be left alone with a patient and that a member of clinical staff must always be present. However, all security staff we spoke with said they were frequently left alone with patients and that clinical staff left as soon as security arrived. We raised this with managers during the inspection, and clinical staff were reminded of their responsibilities. This was a breach of staffing.

During our inspection, we found that staff were able to identify patients whose circumstances may make them vulnerable and when concerns were identified, staff demonstrated an understanding of the safe guarding referral process and knew the appropriate people to contact.

Staff in the paediatric ED knew how to identify children at risk of, or experiencing, significant harm and worked in partnership with other agencies. Staff described the actions they would take when concerned about a child. One member of staff explained that all non‑mobile children who attended with injuries such as unexplained bruising were reviewed by a senior clinician. Staff were also aware of the risks and presentations of child sexual exploitation (CSE) and remained alert to who accompanied young people. A retrospective review of the care and treatment provided to patient’s under 18 years who met certain criteria were routinely reviewed by the safeguarding team to ensure safeguarding referral opportunities were identified. As part of this process the trust had identified examples of possible missed safeguarding referral opportunities that had been shared with staff to inform best practice.

The electronic record system contained safeguarding information for patients of all ages who were at known risk of harm, had experienced abuse or were linked to someone who had been abused. Alerts helped staff recognise risks and take appropriate precautions.

We saw examples of staff assessing and documenting patients’ capacity in their notes. Clinicians were able to explain how they assessed people with mental health needs, including completing appropriate risk assessments. Mental Capacity Act (MCA) training formed part of the mandatory training modules. The department had a safeguarding adults policy and a separate safeguarding children and young people policy. The adults policy outlined staff expectations and required actions when identifying people at risk. The safeguarding children policy was detailed and comprehensive, covering the whole trust and including specific guidance for ED staff on risk factors, who to involve and what action to take.

We scored the service as 2. The evidence showed some shortfalls. 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.

Staff did not always assess and manage risks consistently, including risks related to both mental and physical health. Falls risk assessments were not routinely completed in the department and would only be carried out if a patient was transferred to the acute medical unit (AMU) or admitted. We observed patients with bed rails raised. Inappropriate use of bed rails can increase harm if patients become entangled or attempt to climb over them.

Staff assessed patients’ mental health needs at triage, but they did not always develop and record a clear risk management plan, including required levels of observation or where the person should be placed within the department. There were 2 rooms which staff told us they would usually allocate to patients with mental health needs. However, these were often used for physically unwell patients, meaning that patients with mental health needs were placed in general waiting areas.

We asked the department to send us information about previous risk assessment audits, such as those relating to pressure damage, falls, pain and documentation completion. The trust later sent us information about audits that had mostly taken place after our inspection, following the concerns we raised about risk assessment completion.

In the trust’s evidence submission, the trust acknowledged that recent targeted audits had identified inconsistent risk assessment documentation. A falls spot check showed that 41% of patients over 65 had not received falls screening. Some patients identified as being at risk were given yellow blankets to highlight their needs to staff. However, others relied on family members staying with them to help keep them safe. If family members left, the patient’s risk increased.

On 2 October 2025, after our inspection, the department carried out a pressure ulcer risk assessment spot check for patients identified as being at risk. It was unclear how staff had identified which patients required a skin check. We were not assured the department had a robust method for identifying people vulnerable to pressure damage, although we did see some patients being moved from trolleys to hospital beds during our observations. On the same date, staff completed a pain assessment spot check. Of the 12 patients reviewed, 10 had a pain assessment documented and one person who required pain relief did not receive it. Patients we spoke with told us they had asked for pain relief but waited several hours before receiving it, if they received it at all. Many said they needed to remind staff repeatedly. This was a breach of safe care and treatment.

We observed staff interacting with patients to help them understand their care and treatment. Staff found effective ways to communicate with all patients, including those with accessibility needs. Staff had access to interpreter services, including video calls and translation support. A mobile translation device could be taken to the patient to support communication.

We saw staff encouraging patients to provide feedback about the service. Staff completed risk assessments for each patient on arrival using a recognised tool and reviewed these regularly, including after any incident.

At department level, 68% of patients with symptoms of sepsis received antibiotics within an hour in February 2025. This increased to 91% in August 2025, exceeding the 80% target and showing an improving trajectory .

The department identified patients who required additional input from specialist teams. Staff told us that some specialties, such as care of the elderly, worked closely with ED staff and attended promptly regardless of where patients were located. However, staff also told us that some specialties did not follow professional standards requiring attendance within 60 minutes of request. During our inspection, we saw patients waiting more than 24 hours for specialist review. Many patients could not move to AMU or wards because very few beds were available.

The department had an “Escalation of Acutely Unwell Patients” policy to support staff in raising concerns about a patient’s condition. Staff were assigned roles each shift so they could respond effectively in an emergency when alarms were raised.

We saw patient information leaflets available in the department for people being discharged with certain conditions. These leaflets explained their condition, symptoms to look out for and when to seek further help. Patients could also download the leaflets in different languages.

We scored the service as 2. The evidence showed some shortfalls. 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.

During our assessment, we identified significant concerns about the safety of the environment. We escalated these concerns to leaders in the department and action was taken to start to address the risks.

Staff told us that patients presenting with poor mental health were allocated to specific rooms if they were available. One of these rooms was originally designed to be PLAN compliant, however subsequent changes to the room meant it no longer met all the standards. The other room was designed as a dementia friendly cubicle, this meant the room was not PLAN compliant as it contained risks such as ligature points and unfixed furniture. There was no specific room within the paediatric ED for young people experiencing poor mental health. Patients were placed in a standard cubicle. Staff removed as many risks as possible however, there remained risks to staff and patients using the room, including ligature risks, moveable furniture and a single entry/exit route. This was a breach of premises and equipment.

When we walked through the department, we identified further risks. Open or unlocked cupboard doors exposed consumables that patients could use to harm themselves or others. We also found cleaning chemicals in areas accessible to patients. We raised this with staff, who locked the chemicals away. However, the next day the items had been returned to the original location. Staff were asked again to lock them away. On the third day of our inspection, the items remained secure. Control of Substances Hazardous to Health (COSHH) regulations were not consistently followed, increasing the risk of harm. We also observed oxygen cylinders that were not chained to the wall as required and were left loose on the floor. These issues posed avoidable safety risks. This was a breach of premises and equipment.

During our inspection, we visited the Acute Emergency Care Unit (AECU) which was designated waiting area for patients who were clinical stable and mobile who did not require continuous monitoring. Patients and relatives reported that the area was often unpleasant, due to food and beverage litter left by patients. Some people were observed to be sleeping on benches overnight. Concerns were expressed about patient safety as due to the layout of the area, it was not visible to staff. The concerns were reported to leaders during the inspection and immediate action was taken to improved staff oversight and cleanliness of the area.

We reviewed the resuscitation trolleys in the department. Daily checks were undertaken of emergency equipment.

In the paediatric resuscitation rooms, we found out‑of‑date medicines, overdue PAT (portable appliance testing) checks, and dirty and blood‑stained equipment. The room had not been checked for some time, and some out‑of‑date equipment had not been tested for months. Leaders had not recognised that staff were not completing the checks or documentation required to ensure equipment and premises were safe. We raised this immediately with the person in charge. When we checked both rooms the following day, everything was in order and checks had been completed. We continued to review documentation during the remainder of our inspection, and checks continued to be carried out correctly. Before these issues were addressed, there was a risk that patients might receive out‑of‑date medication or be treated with equipment that was unsafe or not infection‑control compliant. The provider did not have robust processes in place to ensure these checks were completed. This was a breach of safe care and treatment.

We observed visitors being allowed into the paediatric ED through locked doors without security checks or questions about their reason for attending. This meant people could enter the department inappropriately, increasing the risk to children and their families.

We scored the service as 2. The evidence showed some shortfalls in staffing. 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 provide safe care that met people’s individual needs. We found breaches of Regulation 18.

We were concerned about staffing levels in the department and identified a breach of staffing regulations because the provider did not deploy enough suitably qualified staff to meet patients’ needs. At the time of the assessment a decision had been made to employ more staff in the department.

The trust employed a range of staff disciplines across the ED, including nurses, health care assistants (HCAs), resident, middle‑grade and consultant‑grade doctors, as well as emergency and advanced care practitioners.

The trust last reviewed the emergency department’s required staffing levels in March 2025. Establishment staffing refers to the number of nurses needed to safely manage the department and is based on historic patient numbers and patient acuity. The establishment was 18 registered nurses (RNs) and 8 HCAs on day shifts, and 17 RNs and an unspecified number of HCAs on night shifts. The minimum safe staffing level was 15 RNs and 6 HCAs on any shift. The trust told us that establishment numbers were calculated using recognised tools, such as the Royal College of Emergency Medicine (RCEM) recommendations.

When we spoke with staff about their workload and staffing levels, they told us the department needed more staff. They said patients often waited a long time to be seen and to receive care and treatment. Staff told us they sometimes missed breaks and that patient care was affected. Some said their workloads were heavy and they struggled to deliver the standard of care they aimed to provide. Meeting notes also reflected these risks. Although managers were aware of the concerns, the risks remained, showing the department did not have enough suitably trained and qualified staff to consistently meet patients’ needs. This was a breach of staffing regulation.

In March 2025, minimum staffing levels were not achieved on 13 shifts. We also found a significant number of shifts across several months where establishment levels were not reached. Our analysis showed:

• April 2025: Of 90 shifts, 28 (31%) had full RN establishment. Eleven shifts (12%) ran at minimum safe staffing.
• May 2025: Of 93 shifts, 23 had full RN establishment.
• June 2025: 23 of 90 shifts had establishment staffing.
• July 2025: 34 of 93 shifts had establishment staffing.
• August 2025: 17 of 93 shifts had establishment staffing.

This showed the department rarely operated with a full establishment of nursing staff.

We also reviewed how many shifts ran at minimum safe staffing levels. In March 2025, 15 of 93 shifts did so; April, 11 of 90; May, 10 of 93; June, 7 of 90; July, 8 of 93; and August, 15 of 93 shifts. This was a breach of staffing.

The trust told us that during periods of very high demand, additional staff were sought from other departments and senior nursing staff moved from administrative work to clinical shifts. However, this was not a sustainable solution and affected other functions, such as the work of practice development nurses.

We asked the trust for information about staffing red flags between August 2024 and September 2025. Red flags indicate when staffing falls below safe levels or when care is affected by staffing shortages. There were 114 red flags raised: 96 on day shifts and 18 on night shifts. Ninety five related to shortfalls in registered nurse time and one related to missed or delayed patient care.

During our inspection, the department was busy. We saw the impact of staffing levels on patients’ waiting times for triage, assessment, review and treatment. Some areas did not have recommended staffing levels. On our first visit, to AECU the waiting area was full of patients with no staff oversight. We raised this with the trust and, during later visits, we saw clinical oversight in place.

Security staff told us they were often asked to sit with patients requiring 1:1 observation because of their medical needs, such as mental health crisis or confusion. This happened when clinical staff were unavailable. This was not in line with the trust’s policy, which required security staff to always be accompanied by a clinical team member, such as an HCA.

Within the paediatric ED, data from April 2025 to September 2025 showed there were always 3 qualified nurses on duty, in line with establishment. However, during the same period, when one HCA should have worked each day and night shift, there were 103 day shifts with no HCA and 94 night shifts with no HCA, from a total of 182 shifts for each. The paediatric ED worked collaboratively with the Children and Young People’s Unit, sharing staff across the wider directorate. Staff could be moved in or out of the ED depending on need.

We reviewed medical cover and spoke with staff at different levels of experience. The department had 24‑hour medical cover, with overnight cover provided by staff of the correct seniority (Specialist Trainee, ST4), in line with RCEM guidance. Senior clinical leaders confirmed this.

The department had an induction process for all new staff, which included orientation to the emergency department, such as the location of crash trolleys, fire alarms and sharps bins. The induction also covered handover and escalation processes, health and safety, infection prevention and control, medicines management and uniform requirements. Bank staff and staff from other departments were given a picture map showing key areas in the department to help them navigate the environment. Staff working in the ED had the appropriate qualifications for their roles.

Staff told us that training was available, but it was sometimes difficult to access because of how busy the department was and the pressure on staffing. We were concerned that this limited some staff members’ ability to develop their knowledge and experience, which could affect their ability to improve the quality of care they provided.

Staff told us the department was a good place to learn and that colleagues were supportive. None of the resident doctors reported difficulties in asking for help, including overnight. Staff said they could access training relevant to their role and development needs.

We reviewed staff appraisal compliance. Staff told us appraisals were supportive and offered opportunities for feedback and for raising concerns. The trust’s data showed appraisal compliance for nursing staff in the adult ED was 97% and 94% in the paediatric ED. Medical staff compliance across the department was 87%, with plans in place to improve this.

We reviewed training compliance data and found the trust was not meeting its 85% target in several areas. Compliance was:

• Equality, Diversity and Human Rights: Administrative and clerical staff, 67%
• Fire Safety: Administrative and clerical staff, 79%
• Infection Prevention and Control: Medical and dental staff, 72%
• Information Governance: Administrative and clerical staff, 72%
• Basic Prevent Awareness: Medical and dental staff, 71%
• Preventing Radicalisation – Prevent Awareness: Medical and dental staff, 76%

Security staff were a constant presence in the department because there was a history of violence and aggression towards staff and other patients. When we spoke with security staff, they raised several concerns. They told us they were concerned about the level of training they had received to work safely in the department, particularly when supporting vulnerable or violent patients. This increased the risk of harm to patients and staff because security staff had not received sufficient training to work safely and effectively in this environment.

We also found that the trust did not routinely review security staff’s Disclosure and Barring Service (DBS) checks after their initial employment check. The manager responsible for security services told us that staff were expected to inform the trust if they received any new criminal convictions, which was the expectation for all trust staff. We were not assured that this was a robust or safe process.

We reviewed sickness data for the previous 12 months. Sickness peaked at 8% in June 2024, then improved to 4% in February 2025. At the time of our inspection the sickness rate was around 6%.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

Infection prevention and control (IPC) standards were not always maintained in the department. The trust had identified that IPC compliance declined when the department was at its busiest. We raised our concerns with leaders, and action was started during our inspection in response to the issues we found.

We found several soiled items in different areas of the department. For example, specialist lead curtains in the resuscitation area had dried blood on them, and some equipment in the paediatric resuscitation area was also blood‑stained.

The seating in the bereavement rooms was torn, making it non-compliant with IPC Requirements. When we raised this with the trust they informed us that a replacement was already on order. Elsewhere in the department, seating was IPC‑compliant but required cleaning. Staff told us this was difficult due to the constant high demand for seating throughout the day.

When we spoke with patients about the cleanliness of the department, they told us that an area used overnight by patients was often littered with empty food and drink containers. Cleaning staff were not effectively cleaning this area of the department overnight. This was a breach of premises and equipment.

We requested information on cleaning and hand hygiene audits for the 6 months before our inspection. Hand hygiene audit results fluctuated around 80% over the 12 months to October 2025. The trust had already identified shortfalls in practice and had introduced targeted actions to improve compliance, including posters, spot checks, covert observations and immediate feedback to staff.

The trust also provided audit evidence of general IPC checks within the department, including checks of fridges, crash trolleys and PPE use. These audits showed gaps in data collection for some parts of the audit and significant areas of non‑compliance. This was a breach of safe care and treatment.

The trust had an Infection Prevention and Control (IPC) policy dated for review in January 2028. The policy aimed to embed IPC across the organisation and clearly set out staff responsibilities, training expectations and the consequences of not following IPC standards. Staff completed mandatory training in IPC. Medical staff compliance was 88.9% for level 1, 63.9% for level 2 and 47.1% for aseptic non touch technique (ANTT). For nursing staff, compliance was 92.0% for level 1, 86.6% for level 2 and 61.5% for ANTT.

Infection prevention and control audits were routinely undertaken every 6 months unless required more frequently due to an outbreak or low compliance. In July 2025, the environmental audit compliance was 86.8% and the hand hygiene & personal protective equipment (PPE) audit compliance was 76.5%. An action plan was completed to address compliance levels including monitoring of training compliance, repeating audits weekly, and access to an infection prevention nurse (IPN) support daily in the department.

There was enough personal protective equipment (PPE), including gowns, gloves and masks, to protect staff and patients. Sharps bins and clinical waste bins were managed and disposed of correctly. Equipment such as blood pressure machines and ECG machines was visibly clean, and we saw some staff cleaning equipment after use. However, we did not see any “I am clean” stickers in use, and we were therefore not assured that equipment such as commodes was being decontaminated after each use.

We scored the service as 2. The evidence showed some shortfalls in medicines being optimised. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning. We found a breach of safe care and treatment in relations to medicines management.

In most areas of the UEC department, medicines were stored securely in automated medicines cabinets. The trust was rolling out a programme of ambient room temperature checks across the department. There was no established pharmacy service for the department to oversee stock management. UEC staff were responsible for restocking some areas, but there were no support tools or systems in place for the nursing staff member who carried out this task. This increased the risk of errors and meant vital medicines might not be available when urgently needed.

There was no clinical pharmacy service for the UEC department. As a result, patients did not receive pharmacy‑led medicines reconciliation, which is recommended in current Royal College of Emergency Medicine (RCEM) guidance. Of the 6 patients whose notes we reviewed, 2 did not have a complete medicines history recorded. One person had not received their anti‑epileptic medicine, and another patient admitted with mental health needs did not have their antipsychotic medicine listed in their medicines history. Antimicrobial stewardship was not robust; for example, one patient was prescribed an intravenous (IV) antibiotic when oral options had not been fully explored.

We saw examples where medicines were not clearly recorded, increasing the risk of errors. One patient was incorrectly prescribed medicines for alcohol withdrawal, although this was identified by the trust before any doses were given. For another patient, the choice of antimicrobial was not fully explored, despite their inability to take tablets. In a further case, a medicine was prescribed twice, increasing the risk of double administration. This was corrected by the medicines safety officer during our inspection.

Incident data showed an increase in medicines‑related incidents compared with the same period the previous year. The trust told us this reflected a positive reporting culture. Work was underway to collaborate with specialist teams to address identified themes, including prescribing “stat” doses rather than complete withdrawal regimens.

In the 2024 National UEC Survey, the trust scored worse than the national average for “Information on new medications” (Q35). Patients reported that they did not always receive enough information about new medicines prescribed at discharge. UEC staff had access to interpreter services, and multilingual medicines information was available when required.

Patient Group Directions (PGDs) were in place, in date, and supported staff to supply certain medicines before medical review. Competency assessments and sign‑off processes were also in place. Pre‑labelled take‑home medicines were available, and during opening hours, patients could also receive medicines from the onsite third‑party outpatient pharmacy. The department did not keep blank prescription forms that could be dispensed at any pharmacy.

The trust’s medicines policy was in date and set out clear expectations for safe medicines use. However, anti‑epileptic medicines were not included on the trust’s critical medicines list. The trust was reviewing local mental health guidance on managing acute behavioural disturbance, but we saw an example where this guidance was not followed in practice.

The pharmacy department completed controlled drugs audits for the UEC service. Where non‑compliance was identified, managers were notified and an action plan was provided. The most recent antidote audit, from January 2025, showed compliance with antidote requirements.

Pharmacy support and medicines‑related issues were already recognised concerns in the department. Meeting minutes showed discussions about the lack of pharmacy cover at weekends and the impact this had on patient care. The onsite outpatient pharmacy was closed on Sundays and bank holidays, meaning patients could not always obtain medicines promptly unless UEC staff supplied take‑home packs. The range of take‑home medicines held in the department was limited. The trust was considering a different type of prescription that patients could have dispensed at any community pharmacy.