The Hillingdon Hospital

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• 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

We looked for evidence of continuity of care, including when people moved between different parts of the service. We checked that the trust managed risks and met peoples’ needs in a way that was safe. We checked that equipment and facilities supported the delivery of safe care and that medicines and treatments were safe and met people’s needs.

This was a focused follow up assessment for this service; we assessed elements of five quality statements for the safe domain. We looked for evidence that the breach of the legal regulation in relation to safety and risk had been addressed.

At our last assessment we rated this key question inadequate. At this assessment the rating improved to requires improvement. This meant people were safe and protected from avoidable harm.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. Staff 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.

Following our last inspection the trust had initiated several specific workstreams to improve flow through the emergency department (ED). Children under 1 month old and all children arriving by ambulance were streamed by paediatric ED. All other ambulatory children and adults were streamed at the front door. The department aimed to stream adults by an emergency nurse practitioner (ENP) within 20 minutes of arrival but due to capacity and demand this was not always achieved. Children over 5-years old were streamed by a paediatric nurse within 15 minutes of arrival. Patients were then directed to the correct area to meet their needs such as to their general practitioner (GP), ED, pharmacy or the urgent treatment centre (UTC).

Between May- September 2025, the service had seen 70,069 patients, of which 68% had been managed by the UTC, and 2.3% transferred to the ED SDEC pathway. We were told by staff that streaming had improved patient experience and facilitated meeting their needs by the most appropriate service. The friends and family survey results we reviewed had a low response rate although the majority were positive. We also saw several complements that patients or their relatives had submitted.

The UTC had patient champions. Their role was to support patients who following streaming, had been identified that their needs could be met by another service such as a GP, pharmacist or dentist. They supported patients to access these services to ensure their needs were met by the most appropriate service. Data showed that in August 2025, 6.9% of patients had been streamed to an alternative service, which had helped to improve patient flow in the department.

All patients arriving by ambulance, who did not fit the trust’s trauma or acuity criteria, were now assessed using the rapid assessment and treatment (RAT) process, using a recognised national assessment tool. Staff we spoke with stated that the allocated nurse taking handover from the ambulance crews had access to information not only about expected arrival times but also the electronic patient record that the crew had completed. This provided information on their condition, medical history and allowed the nurse to identify the most suitable area for the patient to be directed to. This had improved flow through the department. Staff reported this had reduced ambulance handover delays and enabled them to provide more timely care and treatment.

The ambulance crews we spoke with reported that handover delays had improved. However, they stated that at times they handed over twice, once to the RAT nurse and again to the accepting nurse in the area the patient had been directed to. We were told this was due to the staff in the receiving area not being alerted by the staff in RAT that the patient was being sent to their area. Also the RAT handover notes only being visible to staff delivering care to the patient once the RAT handover had been completed on the electronic system.

The trust tracked whether a patient had been seen by a clinician or assessed in RAT within 60 or 90 minutes of arrival. Data provided by the trust demonstrated that the trust’s target of 75% of adult patients to receive a RAT within 15 minutes of arrival in ED had been met. However, we noted in the last 6 months, the target of patients being seen by a clinician within 60 and 90 minutes was not being met. On average in the 6 months prior to our inspection, 53% of the total attendances were seen by a clinician within 60 minutes of arrival and on average 77% of the total attendances were seen within 90 minutes of arrival. We were told that to promote patient safety, when the time to first clinician reached 1.5 hours, staff were reallocated to support the assessment of patients and to develop a plan for the individual.

At our previous inspection we found there had been a delay in triaging paediatric patients as they were triaged by the urgent treatment centre (UTC) ENP staff. This triage was repeated by a paediatric nurse, following the child or young person being sent to the paediatric ED. The department had revised its staffing model. All children over 5 years were now triaged by a paediatric nurse or those under 5 years were triaged in the ED department by medical staff. In the last 6 months 14,173 children and young people attended the UTC. Data demonstrated that the planned and actual qualified nursing staff was always achieved and there was a children’s trained nurse undertaking the initial assessment. Staffing was reviewed daily and an incident form submitted if it was not possible to have a children’s trained nurse at streaming. In the last six months we noted no incident forms had been submitted. We were told this change to practice had been evaluated to review the impact on patient safety and if it was an effective use of children’s trained nurses. However, we were not provided with the outcome of this evaluation.

The 4-hour performance target of 78% was being met for most months between April and September 2025. Weekly ED senior leadership team (SLT) meetings were taking place. The meetings monitored performance, provided oversight of the implementation and impact of RAT, safety huddles and safer staffing. It was reported these revised ways of working and new processes had improved flow through the department.

Regular monitoring of patient safety incidents in the ED and UTC was undertaken to review the effectiveness of the recently introduced processes such as RAT and safety huddles on patient safety. This was carried out by the divisional governance team and matrons. As the RAT process had only recently been implemented, it was not possible to assess if this new process was having a positive, sustained impact.

Since our last inspection the ‘decision to admit’ policy now included in the ‘bed management’ policy, which had been updated. The emergency department (ED) team in consultation with the ED consultant, were now able to make the decision to admit if no specialty review was required. Those patients who were awaiting a specialist review could be transferred to the acute medical unit (AMU) or surgical assessment unit (SAU) once their immediate needs had been met and they were stable. This approach facilitated decisions being made in a timely manner and reduced the time patients waited in the department. The ED senior leadership team monitored any issues with decisions to admit and used an agreed escalation route to the divisional leadership team and onto the trust executives when compliance issues were identified. We were told there was no formal record of who made this decision therefore it was not possible to be assured these decisions were made in line with the trust’s policy. Following our visit the trust informed us they had implemented a new messaging system which replaced bleeps and had an auditing function. However, as this action had been taken following our visit, we were unable to assess its effectiveness.

It had been identified that there were delays for some patients who required a review by a specialist team, which could impact on the commencement of specialist treatment or transfer to a specialist ward. To monitor response times to requests to specialist teams, we were told bleep audits had been undertaken. However, following our inspection the trust confirmed that formal bleep audits were not undertaken but interprofessional standards where in place. This included if no response to a bleep call was received when a junior doctor was called their middle grade and consultant would then be contacted. If there was still no response this was escalated to operational teams for resolution. Following our visit the trust informed us they had implemented a new messaging system which replaced bleeps and had an auditing function. However, as this action had been taken following our visit, we were unable to assess its effectiveness.

To facilitate timely care and treatment we were told the service had developed and implemented specific pathways for the management of chest pain, early pregnancy and headaches. The ED pathways we were provided with included clear guidance for the safe management of these patients. Staff told us the aim of these pathways was to ensure a high standard of care and experience for these patients by providing timely intervention.

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

The service did not work well with people and healthcare partners to establish and maintain safe systems of care. Staff did not manage people’s safety.

Patient flow through the department was impacted by the number of beds available in the hospital to transfer patients to from the ED. On 3 occasions between May-October 2025, there were 4 days when the full hospital policy was used as there were no beds available in the trust. When the department did not have capacity and all cubicles were full, we were told the temporary escalation area (TES) process would be implemented this included caring for patients in non-clinical areas including the corridor in the emergency department. To reduce the frequency of patients being cared for in this area the trust had identified four additional spaces in the red zone that would be used before caring for patients in the corridor. The trust implemented an updated ‘Temporary Space Escalation’ standard operating procedure (SOP) in July 2025, that reflected national guidance. The SOP included the criteria of patients who must not be cared for in this area, how it was staffed and how its usage would be monitored. We were provided with the numbers of patients cared for in these areas and the average time spent in these areas. However, we were not provided with evidence to demonstrate compliance with the SOP. For example, staffing and if the criteria for those patients not to be cared for in these areas was adhered to.

We were told when patients were being cared for in the additional spaces in the red zone or corridor, staff were assigned to these patients. In September 2025 it was reported 221 patients were cared for in the corridor for on average just over 2 hours. We observed there were no privacy screen between trolleys located in the corridor. This compromised patients’ privacy and dignity.

Data quality issues had been identified by the trust regarding the accuracy of length of stay (LOS) information for patients in escalation spaces, particularly for extended stays. The trust reported it to NHSE in October 2025 when the issue was first identified. Work was ongoing to address the issues and ensure the accuracy of LOS data for patients in escalation spaces. In the last 6 months, 10 incidents had been reported that related to patients receiving care in the corridor. We noted the majority related to the lack of staff to safely deliver care to patients. The impact of these included patients not receiving investigations such as ECGs or blood test that had been requested and in two cases patients had fallen from trolleys.

The corridor where patients were cared for was narrow, which restricted patient movement and access in and out of the blue zone. For instance, it was not possible for a hospital bed to be moved pass the trolleys in the corridor. This posed a potential patient safety risk because it restricted patient movement. To mitigate this risk, we were told any patient who deteriorated would be stabilised before transfer to the red zone via an alternative exit.

Staff allocation was reviewed at the early daily’ huddle’ and twice daily staffing meeting during the day by ED and senior matrons. This ensured any immediate concerns were addressed and changes were made. We were told the trust had formalised the process for allocating staff daily, this included roles and responsibilities for identifying and assigning staff and ensuring appropriate cover for breaks and absences. On the day of our visit, we observed the nurse in charge had oversight of all areas in the ED and flexed staff if a specific area was very busy, while another area had very few patients. This approach assisted with ensuring patients received timely care and treatment.

Staff had oversight of patients in the waiting room in the ED, with a member of staff allocated to this area who was responsible for the observation of patients. To clarify staff responsibilities for patients in the waiting room, there was a standard operating procedure, and compliance was monitored by the matrons and reported to the divisional senior leadership team. The registered nurse allocation sheets for the period 01 September 2025 to 30 September 2025 demonstrated that a nurse and HCA were assigned to this area daily. During our visit we observed that an HCA was present in the waiting room and was undertaking patient observations. There was a triage nurse present in the waiting area who the HCA could escalate any concerns to.

We observed 4 hourly patient reviews were being completed. A range of information was gathered including if they were waiting for a specialty review, their observations and any concerns. This information was recorded on the safety tab of the patient’s electronic patient record (EPR). All records we reviewed included evidence that these 4 hourly checks had been completed. Any concerns were escalated to the nurse in charge during the 4 hourly quality and safety round and were recorded on the electronic system. This provided an overview of the department, identification of any specific patient safety issues such as missed time critical medication and ensured timely actions were taken to improve patient safety and flow through the department.

Staff monitored patients’ risk of deterioration using the National Early Warning Score (NEWS) and recorded this on the EPR. Staff put out an acuity call for any patient with a NEWS score of 5 or above which indicated a risk of deterioration. This ensured the patient was reviewed in a timely manner and provided with safe care and treatment. We were told that an acuity call audit was carried out to review who attended the call and identify any missed opportunities to provide earlier intervention. We requested information about the audit but were not provided with the results or what actions had been taken to address their findings.

The national paediatric early warning system (PEWS) had been introduced in May 2025, to monitor paediatric patients’ risk of deterioration. This was recorded on the electronic patient records, with flags to highlight when a child was unwell. All paediatric staff had been trained to use the PEWS system including how to correctly calculate the score. Maternity early warning system (MEWS) was not used in the department to identify deteriorating pregnant women.

The department was a trauma unit and 96% of its staff were trauma trained. There were plans in place for the practice development nurse to further develop staff in managing trauma to ensure they could provide timely care and treatment to this group of patients. The recent peer review of the trauma pathway, had been positive with only one area for improvement, this was time to head CT. Like many other trauma centres this was an area for improvement.

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

At our last inspection we found the premises and facilities did not always support the delivery of safe care. For example, limited numbers of isolation and ligature free cubicles. This risk had been mitigated and we noted there were two isolation cubicles in the blue zone, equipped and assigned to patients requiring separation for infection prevention and control (IPC) purposes, to promote the safety for both patients and staff. If these cubicles were full or due to the patient’s acuity, for example they need to be cared for in one of the resuscitation cubicles, IPC standards, including those relevant to isolation procedures such as use of PPE were adhered to.

The service had 4 resuscitation cubicles which was insufficient for the number and acuity of patients seen This meant TES areas were often used to accommodate patients when capacity did not meet demand. To review capacity, improve patient care, outcomes and efficiency, the trust undertook a Getting It Right First Time (GIRFT) review of the resuscitation area. This highlighted the areas for improvement which the trust were working on. These included writing a business case to overcome the space constraints faced by the department, which would be a longer-term solution. Following our inspection, we were informed the business case had been approved in October 2025. We were told when demand exceeded capacity in the resuscitation area, patients would be cared for in the red zone. We were provided with a risk assessment that had been completed in September 2025, that outlined the mitigations and controls for the use of this area.

On the day of our visit, we observed that the step-down bays in the red zone were being used to provide additional resuscitation capacity when all the resuscitation bays were occupied. The patient moved to this area was appropriately risk assessed, and staffing adjusted to accommodate them. We were told the trust monitored the risk and mitigations of these actions. We were told the division was monitoring any negative impact on patient safety through incident reports and patient experience data to ensure that the mitigations were effective.

The trust acknowledged that more mental health patients were now attending the department. To ensure their needs were met there were always a minimum of 2 mental health nurses on duty each shift, and 3 HCAs who had received additional training to deliver care to mental health patients. To manage patients at risk of self-harm or suicide, there was an identified ligature light room with double exist and entry points and CCTV designated for better observation of mental health patients. Suitable alternative cubicles could be used if more than one mental health patient was in the department. The identified ligature light room in the ‘blue’ zone had been risk assessed, and action taken to mitigate the identified risks. We noted that work had been completed on refurbishing the en-suite bathrooms in the cubicles and these were now ligature light.

There was no ligature-light room or cubicle in the paediatric ED. We were told that to mitigate the risk when caring for children and young people in the department, all possible ligature risk items such as oxygen tubing was removed from the cubicle. However, to mitigate risks associated with fixed ligature points such as taps, children and young people were closely observed by a registered mental health nurse to ensure their safety was maintained. A bid had been submitted to NHSE to increase the number of ligature light spaces including a ligature light area in paediatric ED.

The Acute Emergency Day Care Unit (AECU) was located on the other side of the hospital to ED. We had previously reported this was not easy for patients to locate. Due to environmental constraints, it was not possible to relocate this service without major building works. During our inspection we noted signage to the AECU was clear and easy to follow. A review of complaints and patient and family feedback did not highlight any concerns with locating this area. It had been previously identified that capacity in the AECU was having a negative impact on flow through the ED. The safety huddle documentation we reviewed did not highlight any themes that indicated capacity in the AECU was having an impact on flow through the ED.

The monthly cleaning report was presented to the trust’s infection prevention and control committee, and an executive summary was provided to the trust board for assurance regarding compliance with cleaning standards. It included information on successes and challenges that impacted on cleanliness. We noted the friends and family survey that was included in the monthly cleaning reports included some negative comments regarding UEC. The evidence provided demonstrated that the trust had responded to the negative survey findings relating to cleanliness.

We saw evidence that as of October 2025, 89% of cleaning staff had been retrained in the correct management and handling of waste and cleaning specific areas such as showers and toilets. We were told ongoing monitoring and regular evaluation facilitated improvements and supported the delivery of safe, effective care environments.

The monthly cleaning audits we reviewed demonstrated that the domestic and nursing cleaning audits were rated as green, compliant. In the ED domestic cleaning was rated green, compliant for 4 of the last 6 months with an action plan to address the areas for improvement with a record of the date the action was completed. Between April and September 2025, nurse cleaning audit results were below the trust target of 98%. It was unclear what action had been taken to address the areas of noncompliance as no action plans were provided to demonstrate how improvements would be made.

Data showed that cleaning of reusable equipment between patient use had decreased from 73% in 2024 to 67% in 2025. It was noted that the data highlighted some areas such as red and blue zones needed to improve. During our visit we observed that equipment was cleaned between patient use. The department used ‘I am clean’ stickers on reusable equipment items when they had been cleaned and were ready to use.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

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

Medicines were stored safely and securely in line with recommendations. Staff had access to emergency medicines. Medicines were prescribed and administered in line with guidance. Records reviewed showed clear documentation of medicines administration.

Since the last inspection, improvements had been made in the security of FP10 prescription forms to reduce the risk of misuse or diversion with a trackable numbering system. A new policy was developed and implemented to ensure the safety and appropriate management of FP10 prescription forms, and we saw this was implemented at the most recent inspection.

Since our last inspection, there was now a clinical pharmacy service provided to the emergency department. Staff told us the pharmacy team was accessible to answer medicines queries and perform medicines reconciliation. We saw evidence of clear communication and recommendations to staff to improve patient safety. Incidents were captured and any actions taken were recorded. Learning from incidents was shared across the team.

We reviewed patient records on the electronic prescribing and medicines administration (ePMA) system that was in place. Although there was no time-critical medicines list available, staff told us this was in the process of being developed pending the hospital’s governance process. Allergies were documented on EPMA records. Staff utilised available resources to enable them to obtain an accurate medicines history from patients.