Basildon University Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At this assessment we rated this key question Inadequate. This meant people were not safe and were at risk of avoidable harm. The service was in breach of legal regulations in relation to assessing risks to the health and safety of patients and the proper and safe management of medicines. Therefore, we were not assured that people were always protected from abuse and avoidable harm.

Patients were at risk of ongoing harm. We found there was no oversight of patients in the waiting room either before or after triage and observed some patient’s health deteriorating in the waiting room without staff noticing to be able to respond to their immediate needs.

The service did not always have a proactive and positive culture to investigate safety events in a timely way. Lessons were not always learnt and were therefore not continually use to improve the quality and safety of the service.

The department did not always work well with patients, the rest of the hospital and health system partners to ensure a safe and effective pathway through the department and onward care. This was particularly evident for patients requiring intensive care or with mental health conditions.

There were not enough staff to safely meet patients' needs or the clinical demand in the department. Senior leaders had not increased staffing levels to meet the needs of their patients at busy times. We observed staff working under significant pressures trying to deliver care and treatment to patients.

The service did not manage the risk of infection well. We found dried and encrusted liquids on the floor in the waiting room, unsecured waste disposal containers, poorly cleaned equipment and bowls on the floor containing bodily fluids. The department was not able to support patients with transmissible infections who needed isolation or barrier nursing because there were not enough side rooms available. Patients were not protected from the risk of acquiring a health-related infection.

There was a lack of effective and reliable processes to ensure the environment was kept clean. Equipment was dusty, chairs were torn, and dirty. There were gaps in records for cleaning various areas. Hand sanitiser containers were left empty until we highlighted this on the second day of our assessment.

Systems and processes to support the safe management and administration of medicines were not always safe. There was a mixture of paper and electronic records which increased the risk of medicines errors, and we found patients did not always receive their regular medicines while in the department. Medicines were not always stored securely, and we found medicines left out in multiple areas.
We found there was a clear structure for safeguarding children and adults. Staff knew how to make a referral and were supported by policies and procedures to keep people safe.

This service scored 31 (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 did not always have a proactive and positive culture to always investigate safety events in a timely way. Lessons were not always learnt and were therefore not continually use to improve the quality and safety of the service.

Not all staff were aware of how to report an incident. Some resident doctors were not aware of how to report safety events and implied this was a nursing responsibility. We spoke to 3 members of staff who had reported an incident but had not received any feedback. This created a risk that not all incidents were being reported, and learning was implemented to ensure patient safety incidents did not reoccur.

Although senior staff in the emergency department (ED) had worked with staff to improve reporting of incidents, for example violence and aggression. We were not ensured learning was being embedded and action taken to improve safety. We observed and heard about similar incidents reoccurring because the root cause had not been identified or addressed. Therefore, there was still a risk that these incidents would occur, and people would be unsafe.

The service compiled a weekly safety briefing for staff. These briefings were read out at handover and shared amongst staff. Whilst the briefing did contain some broad information on patient safety incidents such as pressure sores, medication errors and violence and aggression, staff could not articulate this learning. We observed a handover where the safety briefing was read out and saw that staff were not engaged. At least 4 members of staff were looking at their phones during the briefing and other staff were talking amongst themselves. We asked staff during the day what information had been read out in the safety briefing, and they were unable to tell us.

Although information had been shared about recognition, management and escalation of deteriorating patients staff we spoke to on 10 March 2025 could not recall any incidents about this information in the last 12 months. This includes the necessary training, skills and simulation drills within all areas of the department. Therefore, we are not assured learning from incidents occurs and that there will not be a repetition of incidents resulting in poor outcomes for patients.
There was a risk that learning was not identified in a timely way. Since the trust had implemented Patient Safety Incident Response Framework (PSIRF) staff told us the incident process was taking longer, and senior staff were not trained in completing patient safety incident investigations.

The provider undertook morbidity reviews and for patients who had died within 30 days of leaving hospital. In addition, the provider analysed every death and if there was any learning to be had. For instance, having more proactive discussions re resuscitation to give patients the opportunity to consider options where CPR could have been avoided.

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

The department did not always work well with patients, the rest of the hospital and health system partners to ensure a safe and effective pathway through the department and onward care.

There was a process for streaming patients to the correct area of the emergency department on arrival. However, we saw that this was not effective and led to significant delays and risk to patient safety.

The trust submitted the Front Door Model Standard Operating Procedure (SOP) for the department dated August 2022. This outlined patients who walked into the department would take a ticket, be seen by the navigator nurse for a brief assessment which included clinical observations and be booked in at reception for either full triage or the minors area. If the patient required the resuscitation area, they would be taken there by the navigator nurse

However, the entrance and queuing system was confusing for patients, several patients were unsure where to queue or what they needed to do and there was a lack of accessible and visible signage. There were 2 entrances, each leading to a separate queue. One queue was for patients aged 16 and over to see the navigation nurse and the other was for reception. The reception queue was for patients under the age of 16 and patients who had seen the navigator nurse and were waiting to be booked in. Challenges with the queueing system and triage were a key theme highlighted in the service’s friends and family test data from July to December 2024.

Despite a combination of support for admissions and triage to the emergency department (ED) from ambulance staff, there were significant delays for patients brought in by ambulance. We observed a patient with a serious injury who was not provided with safe care when staff did not take appropriate action to immobilise the patient risking further injury and permanent damage.

Two additional patients were brought in by ambulance with chest pain and experienced delays of 6 and 8 hours to see a clinician. One of these patients waited 6 hours for an ECG. Although this specific case did not result in immediate harm to the patient, it highlighted the serious risks associated with delays in accessing appropriate clinical care and the absence of proper senior leadership oversight.

During our responsive assessment on Monday 10 March 2025, staff we spoke to in specialist teams said ED staff did not always follow the treatment pathways in ED and would tend to escalate to Intensive Treatment Unit (ITU) for support and assistance. Staff were not aware of correct referral triggers to specialist teams and would escalate based solely on their own clinical judgement. A registrar or consultant from HDU would respond to any escalation made, however ED staff felt this response was not consistent. The trust was unable to demonstrate clear and current standing operating procedures in relation to the recognition, management, escalation of deteriorating patients within the department.

Staff in the department identified people with mental health needs at triage. The triage form included details about mental health. If a person needed mental health support, staff would refer them to the psychiatric liaison service, provided by the local mental health trust for assessment. The psychiatric liaison service did not complete assessments at the same time as the person’s physical health needs were being assessed as recommended by the Royal College of Emergency Medicine (RCEM) where possible. This meant that people may spend more time in the department.

The service did not have a robust system in place to ensure staff delivered therapeutic observations for people with mental health needs who required support. When required, shift leaders allocated members of staff to observe people with mental health needs. Members of staff told us they found it hard to do this task due to the department being busy. They also felt they needed training on how to deliver therapeutic observations. A specialist mental health nurse could be requested from an agency, but members of staff told us that they took time to arrive, and the shifts were not always covered. Staff told us there was a risk that a person with mental health needs would not be observed and come to harm. The trust recognised this after our assessment and added it to their risk register.

The provider and the local mental health trust had made changes to support people with mental health needs to access specialist services directly and quickly. Patients whose primary concern was mental health could be directed straight to the Mental Health Urgent Care Department, operated by the local mental health trust in a separate building on the Basildon hospital site. This meant patients whose primary need was for mental health support no longer needed to attend the ED and could access specialist support directly. The number of patients presenting to the department with mental health as a primary reason had decreased between July and December 2024, from 292 to 209 patients.

Staff told us that the national initiative by NHSE for 45-minute ambulance patient handover (HO45) procedure started on 27 December 2024 but stopped again on 30 December 2024. Staff did not know why the procedure has stopped or if it was likely to be restarted again.
Patients did not have all their individual health care risks assessed. Staff told us this was due to time constraints and short staffing. We reviewed 6 sets of clinical notes and 4 of these did not have the relevant risk assessments completed. For example, patients did not have their risks of falls or pressure areas effectively assessed.

We saw confidential patient information was not always stored securely. The notes for patients in the majors seated area were stored in a tray on a surface opposite the area. Although the area was incredibly busy, patient notes were often not put away and were sometimes left open on the desk. Additionally, handover sheets with confidential information were left in view of patients and visitors. In the resuscitation area we observed doctors and nursing staff leaving computers with confidential information open and unattended whilst visitors walked past.

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.

Staff had completed training on safeguarding children and adults. We did not delve further into children’s safeguarding as we covered this at a previous assessment.
Staff understood their responsibilities and adhered to safeguarding policies and procedures.

There was a clear structure of leadership for safeguarding children and adults. There was safeguarding leads in both adult and children’s emergency departments who fed into an Associate Director of nursing and then Chief Nursing Officer.

Where people had an identified safeguarding concern, such as a pressure sore, this was always reviewed by an appropriately qualified staff member and referred to the local safeguarding authority as a matter of routine. This promoted good practice but also helped with any learning for stakeholders that could be involved in the patient’s care.

Policies and protocols were in place to help prevent any unsafe discharges against medical advice. If a child, young person or parent / carer left the department without being seen, the medical team responsible for the child would be informed immediately and a risk-based assessment would be completed. This situation had to be clearly documented in the Children’s Emergency Department (CED) and Paediatric Assessment Unit (PAU) healthcare records. Any immediate risk would be escalated to the appropriate authorities in returning the child/young person back to the department for assessment.

Decisions were made in patients' best interests in accordance with mental capacity guidance and legislation. Staff checked people understood any decisions made about their care and treatment. Such as, an appropriate adult with parental responsibility or a legal representative with a power of attorney. Where it was deemed necessary to consent to self-discharge, staff made sure this was safe. Staff respected patients’ unwise decision making where the patient had mental capacity to understand any consequences.

The provider’s annual safeguarding report showed that since focused workshops, training and development of simple guidance around DoLS and mental capacity assessments, there had been significant improvement in staff skills and knowledge in identifying patients who lacked mental capacity to give consent to their care and treatment. This led to appropriate use of the DoLS legal process to ensure patients’ human rights were protected and care was delivered in their best interest. For example, applications of DoLS had increased from 194 in the 1st quarter of 2023 to 305 in the 4th quarter.

The trust had an enhanced supervision policy for mental health patients requiring physical treatment, but there were not enough trained mental health staff to complete observations. The psychiatric liaison team decided how often someone needed to be observed. Sometimes the ED nurses would try and escalate that a person needed to be reviewed, but the psychiatric lead did not rereview the patient. Staff however, told us they felt they would benefit from additional training in this area.

The provider did not work well with people to understand and manage risks. Staff did not 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 effectively manage risks to patients.

During our site visit on 17 and 18 December 2024, the provider was using a nurse navigator but the arrival and booking in process was confusing for patients. Patients were not recorded in a timely manner upon entering the department. This increased the risk of delays in care and a risk of harm occurring due to delays accessing treatment.

There was a risk patients could deteriorate whilst waiting to be recorded as having arrived in the department. We observed, and staff and patients told us, that during busy times the check in process could take 1-2 hours. We observed the waiting room and saw multiple patients awaiting review by the navigation nurse, 4 patients told us that they had been waiting over an hour to be called by the navigation nurse.

Data submitted by the trust showed from July 2024 to December 2024 the initial assessment time was between 2 minutes 34 seconds and 3 minutes 39 seconds for walk in patients. The time to full triage was between 24 minutes and 42 seconds and 36 minutes for walk in patients. However, the navigator nurse only documented the time they saw the patient so any time prior to this was not recorded. Therefore, these figures did not capture the real waiting time for patients and our observations during assessment reflected significantly higher waiting times. This posed a risk that patients with serious and time critical health conditions may be delayed in getting essential care and treatment.

The data also showed from July to December 2024 patients arriving by ambulance waited between 2 minutes 15 seconds and 3 minutes 25 seconds for initial assessment. The time to full triage was between 20 and 30 minutes for ambulance arrivals. While observations on assessment did not call this data into question, it did not meet NHS England national guidance which states patients should be triaged within 15 minutes of arrival.

We observed a lack of clinical oversight and leadership in the waiting room during our assessment in December 2024. Staff told us about incidents where patients had deteriorated in the waiting room without a clinical member of staff noticing.

Some patients in the department were positioned out of sight of staff, such as around corners. This meant that unless staff physically passed by these patients, they wouldn’t be aware if the patients had deteriorated, needed assistance, or were at risk of harm. This was a risk identified in the provider’s risk management tool. During our December assessment we observed a patient to be laying on the floor of the waiting room during the afternoon. We spoke to the patient who told us they had not been approached by staff to check on them.

Following our December 2024 assessment site visits the provider told us a “waiting room team” consisting of a nurse and health care assistant (in addition to current staffing) had been implemented to maintain oversight of the waiting room, signpost patients and manage the queue. However, during our assessment on 8 January 2025, we found the waiting room team was not always staffed. The provider told us they would put additional staff in the waiting area to mitigate the risk of timely triage and streaming of patients but had only funded staffing for 50% of the time. Our assessment team had to intervene on 2 occasions to alert staff to patients who had rapidly deteriorated. One patient was pale and visibly shaking, CQC team members alerted staff, and the patient was taken to the resuscitation area. Later that day, the team had to alert staff to a patient having a seizure in the waiting room. The trust provided assurances on 20 December 2024 detailing how the risks would be mitigated.

We asked the trust to submit the number and details of patient safety incidents in the waiting room for the last 6 months including the period of the assessment. The trust submitted information which showed 3 incidents had been reported where patients had deteriorated in the waiting room. However, the 2 incidents escalated by CQC referred to above were not included in the information submitted. This reflected that not all incidents for patients deteriorating in the waiting room were reported.

The service used a sepsis screening tool. Sepsis is a serious complication of an infection which, without quick treatment, can lead to multiple organ failure and can be fatal. The provider’s August 2024 sepsis audit findings was 88% for sepsis screening.

During our assessment on 10th March 2025, staff we spoke to raised concerns about the capacity and risk management within the resus area. They stated there were only 2 nurses allocated to this area, when there is high demand, they rely on patient’s relatives to alert staff if a patient deteriorates.
Staff informed us that the electronic system they used to record patient’s observations was not suitable for the emergency department and was more a ward-based system. Staff told us they often ignored the system prompts for clinical escalation as they felt it not necessary. The service was unable to demonstrate real time auditing processes to monitor the observations system for recording patient observations. The service was also unable to demonstrate clear overview of deteriorating patients within the whole ED and was unable to demonstrate appropriate escalation processes had occurred, which put patients at risk of harm.

The decision to postpone the 45-minute ambulance handover (HO45) process was not effectively communicated to staff. Staff did not understand the rationale for this decision or when the process would recommence. There were no checklists, risk assessments or clear roles and responsibilities regarding HO45. However, the leadership team informed us these were being developed, at pace, to support and assist staff. We wrote to the provider on 17 January 2025 inquiring if this had been completed, they told us they had now developed a protocol.

There was insufficient space in the department to meet the high number of patients. Staff told us patients identified by staff as being at risk could not always be moved into the main ED area. We saw 1 patient who presented with a rectal bleed being cared for in an inappropriate area (not in line of sight and not in an area where emergency equipment could be accessed quickly in an emergency). All the medical staff we spoke with voiced their concern about patient safety and a lack of space to examine patients in the department. Some staff told us the leadership team prioritised ambulance queues and overlooked other critical issues staff had raised. For example, staff felt that assigning an additional nurse to the resuscitation department was also a priority that needed attention.

However, patients fed back in the Friends and Family Test (FFT) survey that from the information they were given by hospital staff, the service scored better than the NHS average for how patients were able to care for their condition at home. One patient we spoke with told us they were attending the department for a recurrent health issue and knew what to do if they were dehydrated. However, since their arrival they had not been administered any further pain relief, had not been seen by a doctor and were not sure what the plan was for them.

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

The department was divided into four main areas. In one of these areas, the majors’ seated treatment area, the seating was not suitable for patients to sit comfortably for extended periods.

The service did not always control potential risks in the department, including but not limited to infection prevention and control, the environment and falls. The provider did not ensure equipment and facilities supported the delivery of safe care. The environment was too small, with trolleys in corridors. The provider did not always fully consider the impact of changes on the additional capacity measures, such as increasing trolleys for ambulance handovers. This meant some trolleys were not visible to staff and the overcrowding meant staff may struggle to respond to clinical emergencies in the environment.

Corridor care also made it difficult to use necessary medical equipment. Whilst staff were aware and managed some risks associated with corridor care, we found a lack of risk management oversight necessary to keep patients safe and minimise the risk harm to patients from receiving care in an inappropriate area. There were no call bells in areas where patients were receiving corridor care. This meant patients may not be able to alert staff should they need urgent help. In addition, the resuscitation area did not have call bells which was recorded on the provider's risk register as of 20 January 2025, had been escalated to the senior leadership for approval. This meant if any patient needed urgent assistance, they may not be able to do this if they could not speak. We were told the funding for these had now been agreed but there was no planned date to install these, and we did not see any interim arrangements to keep people safe.

Further, some patients were placed next to the ambulance offloading door, which was frequently left open, creating an uncomfortably cold environment. This was because staff often needed to check on patients waiting in ambulances outside.

We found hazardous materials were not managed in line with current legislation and guidance for Control of Substances Hazardous to Health (COSHH). We observed 3 cleaning trolleys unsecured and unattended which contained substances subject to the COSHH regulations. We found 2 instances of hazardous substances being left insecure and unattended, again the day after we raised these concerns with senior staff. This indicated that staff were not effectively managing the risks associated with harmful substances, putting patients at risk of unnecessary harm. Notably, on our third visit we found there had been improvements made to the security of hazardous substances.

We found gaps in the daily checks of emergency resuscitation equipment. For example, we reviewed the daily checks for the resuscitation equipment in the majors’ light area between 18 November 2024 and 18 December 2024 and found records had not been completed on 6 days. There was no standard Automated external defibrillator (AED) sign which should be used to reduce delays in locating a defibrillator in an emergency in line with the Resuscitation Council UK Quality Standards.

We found a coat hook on the back of a toilet door near the main entrance, which we identified as a ligature risk. We noticed later in the day that the toilet had been taken out of use, we also informed senior staff of the ligature risk. One patient told us that the toilets were not suitable for the elderly because they did not have mobility aids necessary to support people. A senior staff member was responsible for auditing ligature points including coat hooks on doors but had not identified this until we highlighted this risk to senior staff.

The service did not 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 work together well to provide safe care that met people’s individual needs.

There were not always enough skilled and experienced staff in the department. The leadership told us this was due to recruitment challenges. Spending controls and staff turnover also affected staffing in the department. There were not always the required numbers of mental health nurses available, however the risk was in the main mitigated by using agency staff.

Senior leaders had not increased staffing levels to meet the needs of their patients at busy times. We observed staff working under significant pressures trying to deliver care and treatment to patients.

The department used a safer staffing tool which showed 16 qualified nurses, and 5 emergency technicians (ET’s) were required on each shift. The planned staffing establishment, which should additionally consider patient needs and staff skill mix was 19 nurses and 6 ETs on a day shift and 18 nurses and 5 ETs on a night shift. We reviewed the staff rota between 18 November 2024 and 18 December 2024, on one occasion staffing levels fell below safer staffing levels and on 14 occasions staffing was below planned staffing. The matron's told us that they would work clinically to cover any shortfalls. Planned staffing would be the ideal and safer staffing would be a minimum.

We observed staff working under significant pressure when patient numbers were high. We found the staffing establishment did not match the amount and acuity of patients that attended the department. Staff also told us the department did not have sufficient staff to meet the needs of the service. In response to clinical incidents, it had been agreed that each shift would have an additional nurse and two ETs. This arrangement began on 12 November 2024 but was discontinued 22 December 2024. Staff did not know why this had been discontinued.

Staff did not think there was enough staff to carry out their jobs. The staff survey showed division 1 (emergency department and acute services) scored 3 points lower than the organisation average for the question “enough staff to do my job” (21.4% against organisation average of 26.8%).

The provider told us on 10 January 2025 they would continue with additional staffing and review this. However, from our visits we found staffing was insufficient as cover in the waiting area was only for 50% of the time. The provider told us in their mitigation response to our serious concerns, that they would implement additional staffing in the department waiting area. However, we found these staff were either elsewhere or being used for other tasks.

The department used minimal agency staff. Between 18 November 2024 and 18 December 2024 agency staff had covered 8 shifts. The senior staff explained that previously there had been issues with agency staff not having the access to IT systems. This had been resolved as long as these staff completed an induction, but there was not a specific induction programme for agency staff. Senior staff told us new agency staff had a tour of the department. Also, there was no way of knowing in advance the skills and competence of agency staff. This meant that they did not have a full picture of patients. Due to a lack of access agency staff had been sent home, leaving unexpected shortages of some skill sets and planned staffing levels.

During our assessment on 10 March 2025, we found that there were concerns about safe staffing levels and skill mix per ED area, for both medical and nursing staff in the ED. Despite identifying the need to increase nursing staffing in December 2024, this had not been fully implemented and was awaiting trust board approval in April 2025. Staff informed us that on occasions ED resus nursing staff were not available to support the transfer and handover of a patient to ITU. This lack of progress following identified staffing risk was putting patients at risk of harm in the department.

At the same assessment, leaders were unable to demonstrate how they ensured there was adequate distribution of skilled staff across the department. Therefore, there was no assurance that the nursing and medical skill mix across the ED would have the necessary competency and skills to identify, manage and escalate patients in response to fluctuating demand potentially leading to poorer clinical outcomes for patients.

The trust submitted information showing there was a vacancy rate of 15.59% (full time equivalents) for nursing staff and 19.33% for medical staff in the emergency department. The data also showed that the department was slightly overrecruited for emergency nurse practitioners by 0.85%.

Staff in the emergency department were organised into teams for training and development. There was a practice education facilitator who oversaw training and designed a study day for each team every 5 weeks. We heard that a senior staff member had recently attended each study day to deliver some training on the importance of reporting incidents. As a result, the number of incidents reported had increased.

All medical staff had protected time to attending formal training and had regular clinical supervision and had open access to their supervisors. Staff told us that the recent reduction in available hours for locum doctors had a negative impact on the increased crowding in the department.

Staff told us they had appraisals as needed and found these to be meaningful, but due to ongoing pressures, there had been a decrease in the completion of appraisals.

The service did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The service did not manage the risk of infection well. For instance, we saw found dried and encrusted liquids on the floor in the Emergency Department (ED) waiting room, unsecured waste disposal containers, poorly cleaned equipment and bowls on the floor containing bodily fluids. The department was not able to support patients with transmissible infections who needed isolation or barrier nursing because there were not enough side rooms available. Patients were not protected from the risk of acquiring a health-related infection.

On the first day of our assessment, we found bowls containing bodily fluids which were left on the floor all afternoon despite us raising this issue with staff. We found a used swab left next to a computer on a desk which was neither labelled nor disposed of safely. We raised this with staff to ensure the swab was safely disposed of and the area properly cleaned. Staff took immediate action.

Trolley mattresses materials were torn and dirty, staff had used adhesive tape to cover over the holes. The seating in the waiting area was not fit for purpose. The seats were badly damaged, and the absorbent foam was exposed. At another assessment we undertook for paediatric services in November 2024, we escalated these concerns to the senior leadership team, but the issue remained on 18 and 19 December 2024. This meant the mattresses and waiting room chairs could not be cleaned effectively and continued to pose a risk of exposing patients to infection.

Clinical waste was not stored securely in line with the provider’s policy. We saw the clinical waste room was unlocked, despite posters on the doors stating the doors should be kept locked. The unsecured clinical waste room posed a risk of injury, infection, and exposure to hazardous materials.

In the waiting area there were multiple items stored on the floor preventing effective cleaning of the floor and increased the risk of contamination. Items included carboard boxes, sharps containers and litter. A relative told us they had, “raised concerns about how filthy the department was today” and said, “It was the same when I came in April [2024].”

Infection prevention and control (IPC) audits within the department showed compliance ranged from 40% to 93% from January to December 2024. During this period half of results (6 months) were below 70% and only 2 months (April and May 2024) scored 90% or above. The audits had not prompted effective and timely action.

The infection prevention and control quarterly report for October to December 2024 highlighted several issues with infection control including inappropriate use of personal protective equipment, dirty commodes, stretchers not being cleaned and staff not being bare below the elbow. It highlighted an increase in infectious cases through the department including a case of measles which had not been isolated properly.

We found the environmental cleaning records had not been completed. The omissions had not been identified or escalated. The gaps in the cleaning schedule were not identified and the processes to monitor cleanliness were not effective.

Hand sanitisers at hospital entrances are important to reduce the spread of harmful bacteria and viruses, protecting both patients and staff from infections. We observed 3 empty hand sanitisers at the entrance to the department on the first day of our assessment. They remained empty on the second day of the assessment despite the assessment team making staff aware.

Cleaning schedules were in place, but these were not adhered to or followed. We saw there were gaps in the patient cubicle checking and cleaning schedules. For example, cubicle 7 in majors light was missing 4 daily checks between 1 December 2024 and 18 December 2024. We also saw overflowing waste bins in the waiting room.

Staff had access to enough Personal Protective Equipment. We observed staff using and disposing of this correctly. We also observed staff were bare below the elbows in clinical areas in line with national guidance. The department had a designated infection, prevention and control lead and all staff had had relevant IPC training. We observed staff using hand sanitisation products as needed.

Governance meeting records showed that between October 2024 and December 2024 there had been no cases of methicillin-resistant Staphylococcus aureus (MRSA) bacteria or Clostridium difficile (C. Diff) cases in last month.

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Systems and processes to support the safe management and administration of medicines were not always safe or robust. The emergency department was using both paper records and an Electronic Prescribing and Medicines Administration [EPMA] system. This was because the medicines could not be added to the electronic system until a medic had accessed the GP medical history and set the patient up on the trust electronic system. Urgent medicines, such as pain relief and antibiotics, were added to the paper charts so they could be administered straight away. However, staff told us medicines errors had been made because the paper charts had been misplaced, and patients had been double dosed with medicines or doses had been missed. This meant people were at risk of not receiving their medicines as prescribed and their health conditions deteriorating. The incidents had been reported using the internal reporting system, however there had not been any effective action taken.

Patients were not always receiving their regular medicines while they were in the emergency department. Some patients brought their medicines with them, but these were usually not used. The only medicines administered were those kept as stock in the emergency department. We found the delays to administering time specific medicines caused patients confusion and increased the risk of harm, such as from falls. This meant patients who were prescribed critical medicines such as insulin and medicines for Parkinson’s disease were often not receiving these. Staff told us patients were often transferred to wards without receiving their medicines because the staff had either not had time to administer them or there were agency staff on duty who could not access the EPMA system as they had not been trained.

Some patients did not have their medicines reviewed until they were admitted to a medical ward. In some cases, this was 24 hours after the patient presented at hospital and meant they missed time critical medicines.

The provider’s October and December 2024 friends and family test survey responses highlighted a lack of oversight and a lack of support for patients to take medicines. It also highlighted lengthy delays, for prescribing or administering medicines.

Medicines had not been stored safely or securely. In the resus area the medicines cupboard containing emergency medicines was observed to be open during the day of the assessment. Medicines had been left on counter tops and the medicines keys, which included the controlled drugs cupboard keys, had been left unattended. We saw several members of staff, including senior staff walk through this area without taking an action. We observed one nurse came and took medicine from the cupboard but left it unlocked and the keys unattended. We saw from staff briefings that controlled drugs had disappeared from the cupboard and could not be accounted for.

The main medicines storage room on majors was dirty and the pharmacy delivery had been taken out of the delivery boxes but not put away. There were loose strips of tablets in the stock cupboards and a prepared bag of fluid had been left on the counter. The fridge contained expired medicines and medicines for people who were no longer in the department. Some of these were dated August 2024.

The temperatures of stored medicines were completed with a handheld device and the readings were recorded on paper. Room and fridge temperature checks and daily room checks were not being completed daily in any of the medicines storage areas we looked at. This created a risk to people because medicines can become less effective if they are stored at a temperature outside of safe storage limits.

However, there was a regular pharmacy service to the emergency department and staff could contact the pharmacist using the bleep system. The pharmacy completed audits for antibiotic prescribing and attended monthly governance meetings. Information was shared via the staff briefing each week which was written by the Matrons and contained information about incidents and lessons learned. We also observed some people who were able to manage their own medicines, such as for diabetes.