Dorset County 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

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

At our last assessment we rated this key question Requires improvement. At this assessment the rating has changed to Good. This meant people were safe and protected from avoidable harm.

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.

Staff had access to a range of mandatory safety related training subjects, in addition to other speciality related topics. An internal review of mandatory training was taking place to reflect the national framework of mandatory training provision. This was to ensure staff only completed mandatory training for their respective role.

Staff followed guidance on the National Patient Safety Incident Response Framework. The Patient Safety Incident Response Framework (PSIRF) focuses on learning from incidents to provide safer care to patients. We saw posters explaining PSIRF were displayed on wards and these indicated how patients, families and staff could be involved. The Patient Safety Incident Response Plan was approved and published in Board papers available on the Trust website in June 2025. The trust also used the Infection Prevention Management Patient Safety Incident Response Framework (IPSIRF). This helped the service to identify themes and trends, and for the development of learning.

When things went wrong or there was a near miss, staff used the formal process to report these incidents. These were investigated and any learning was shared with staff via meetings, safety brief huddles, emails, newsletters or face-to-face. We saw for example, evidence of learning shared within minutes of the Cardiology Governance and Quality Meeting. This related to pacemaker follow up. An after-action review had taken place, and the pathway had been made clearer as a result.

Staff understood the importance of reporting and the process to follow. Staff had access to the incident reporting policies and procedures found on the trust intranet. They were able to give examples of matters reported and the actions taken because of the learning. For example, alteration in the pathway through endoscopy for patients with known Tuberculosis (TB). Tuberculosis is a contagious, airborne bacterial infection affecting the lungs.

There were ‘Stop for 5 minutes hot debriefs’, where staff could review adverse events and identify learning. We saw examples where the Duty of Candour (DoC) legislation was mentioned from such discussion. This legislation requires healthcare organisations, including hospitals, to be open and honest with patients when things go wrong during care. This meant being transparent about what happened, offering an apology, and explaining any investigations or actions being taken. It also ensures patients are informed and involved in the process of addressing the incident. We heard examples where staff had followed the process to apologise. This included when a medicine error occurred, when a patient fell on the ward or developed a pressure ulcer. Ward leaders and deputy sisters had been trained in DoC.

Morbidity and Mortality (M&M) meetings were used to identify learning from patient outcomes. Each speciality held its own M&M meeting to discuss unexpected deaths and other complex patients. Staff told us these meetings were open to anyone, not just senior staff. There was also a trust wide mortality group meeting, which staff from different areas could attend. We heard an example of recent learning, which related to improving communication with patients and families about their expectations when having a medical procedure.

There was a process for responding to central alerts about safety, which included notifying the medical services about national safety alerts.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Referral processes, admission criterions and the assessment of patients’ immediate needs ensured their ongoing safety. Patients received safe care and treatment because of well-developed pathways, which were in line with best practice guidelines. For example, there were pathways for admission from the Emergency Department (ED) to the Frailty Same Day Emergency Care (FSDEC) Ward; for stroke patients; admission criteria for elderly care, and direct admission for some medical specialties.

The FSDEC was a relatively new service which had been open for 1 year at the time of the inspection and aimed to support the flow from the Emergency Department. The FSDEC was an advanced practitioner led service with clinical support from geriatricians to review patients as required. Referrals came from ED, GPs, community frailty teams, the NHS ambulance service and Urgent Care Teams. The team aimed to provide holistic, timely assessment and treatment for older people at risk of admission with the goal of avoiding admission to hospital and supporting people to live well at home. An admission criterion ensured only those suitable were directed to the department between the open hours of 8am to 6pm, Monday to Friday. Approximately 30% of patients who came to the FSDEC went to other areas within the hospital and 70% were discharged following diagnosis and any required treatment. However, staff reported recent issues, which indicated the unit was not always used as intended. This included having bedded patients boarding, rather than moving to a ward due to problems with patient flow further along the line. At such times, they were cared for by staff from the opposite ward.

The Acute Medical Assessment Unit was on Evershot Ward, where patients were accepted based on an admission criterion. The ward did not accept patients who were frail, had dementia or a Clinical Frailty Score (CFS) of 6 or above. Most patients stayed on this ward for 72-hours, with 50% being discharged directly back home.

Despite best efforts, patient flow was a challenge. For example, medical patients had been bedded in Day Surgery and the Discharge Lounge overnight on the first day of inspection. However, bed management meetings and board rounds were used to discuss patient flow and safety. There were Bed Management and Patient Flow Policies to help staff manage activity. Matrons and ward leaders worked closely with the wider multidisciplinary team to ensure patients were as safe as possible, not just at admission but throughout their stay and preparing for discharge. The latter included when people were medically fit for discharge but were awaiting social workers and agreement of packages of care. The complex discharge team supported the arrangements related to ongoing care to ensure the patients safety was not impacted. As a result of work by the Transfer of Care (TOC) process, the trust had seen improvements in the discharge figures. Reduction in length of stay was ahead of target. This was mainly because of earlier referrals and earlier identification of patients by the TOC and same day decision making, with70% of discharge decisions being made within 24-hours.

Patients told us they felt safe and cared for, even when they were located on the corridor in the Emergency Department (ED) before moving to wards. They reported being triaged quickly and moved to other areas within the department whilst awaiting next steps.

We scored the service as 3. The evidence showed a good standard. 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 shared concerns quickly and appropriately.

The trust had lead safeguarding professionals, including a named doctor, midwife and nurse, which met the requirements as detailed in Working Together (2023). Staff knew who the safeguarding leads were. Safeguarding policies were accessed on the hospital intranet. They provided directions and advice to staff on their responsibilities. Staff were also provided with safeguarding training at levels 2 or 3, depending on their role. Safeguarding training across all levels, 1 to 3, was 89% across the medical service against the trust target of 90% compliance. Staff could demonstrate their knowledge of the subject accordingly and gave us examples where they had raised safeguarding referrals. There had been 9 concerns raised in the 6 months prior to our site visit. Enquiries which went forward for consideration by the Local Authority included financial abuse, neglect or omission, physical and domestic abuse.

Staff followed safe procedures for children visiting the medical wards. There was secure access to wards and people were only let in after announcing who they were via the intercom.

A policy was available to guide staff about the use of restraint and restriction to ensure they were not used incorrectly. This included the legal frameworks for restraint, who could or could not carry out restraint, and the training requirements. Staff told us they tried to avoid using restraint on patients by understanding them, their needs and pre-empting triggers. Where restraint was unavoidable, we were told this was done so by the dementia team staff and security staff who were trained to do so. Physical intervention training was provided to only those staff who may have needed to use this approach to secure the patients safety. Data provided showed 19 restraints had been carried out during 2025. A full record of the situation and reason for applying the technique was made, including if any harm happened and any learning for staff was identified.

There was a hospital wide policy for the use of rapid tranquilisation where individuals were extremely agitated or were showing disturbance of behaviour. The aim of any such intervention by staff was to minimise harm and violent behaviour.

We scored the service as 2. The evidence showed some shortfalls. Although the service worked with people to understand and manage risks by thinking holistically, people with suspected sepsis did not always receive timely care and treatment.

Staff had access to a range of policies and procedures to inform the delivery of safe care and best practice to patients. This included assessing patients and identifying risks, so they could be safely managed. We saw the Rockwood Frailty Scale was used to score patients, a core of 1 being independent and 9 to indicate terminally ill/dying. Care records showed an initial assessment of patient needs and any risks, along with the action staff were to take to minimise such risks. For example, patients with reduced mobility and/or having fragile skin were nursed on specialised mattresses, had their position changed regularly and skin checked for any possible damage. Risks of blood clots occurring were assessed and recorded on the electronic patient medicine record, along with any prescribed preventative medicine and re-assessment at 24-hours.

Staff followed a deteriorating patient pathway when the need arose to escalate concerns. We saw staff used a nationally recognised tool, known as National Early Warning Score (NEWS2), to identify deteriorating patients and escalate their concerns to medical staff for review. Our review of patient records showed staff completed these assessments and scoring systems and acted as needed. Concerns could also be escalated to the Critical Care Outreach Team, which included 1 advanced clinical practitioner during day hours and 2 at night, 24/7. They were requested either via a bleep system or at the clinician handover.

There were suitable escalation and de-escalation protocols for staff to follow. The escalation process included sharing information about the patient based on the principles of ‘Situation, Background, Assessment, Recommendation' (SBAR). We saw evidence of escalation having taken place and the actions taken recorded in the patient records. Audits had shown the main users of the outreach service was respiratory, cardiac and renal wards.

However, not all adult inpatients with suspected sepsis received timely care and treatment. There was a sepsis pathway for staff to follow, which was based on best practice for recognition, diagnosis and early management of patient deterioration. Staff compliance with this had been recently audited between July 2025 and September 2025 which showed staff did not always follow agreed processes in line with nationally recognised rapid response protocols, such as ‘Sepsis 6’. This related to blood tests within expected timeframes. However, patients usually received IV antibiotics in the first hour of suspected sepsis and none of these patients reviewed as part of the audit had adverse outcomes due to lack of appropriate care. Recommendations and actions for improvement had been identified, one of which related to improving documentation. However, these were not going to be discussed at the Deteriorating Patient Group until January 2026, despite having results available sooner. This meant there were missed opportunities for learning and driving prompt improvement in this area.

Where patients and their families, friends, or carers were concerned about aspects of treatment and care there was a process to raise these issues under Martha’s Rule. This is a patient safety initiative in the NHS in England allowing patients and families to request an urgent, 24/7 second clinical opinion if they fear a condition is worsening and not being adequately addressed. Matters could be raised via the Call for Concern phoneline, which was then triaged by the Critical Care Outreach Team (CCOT). This included the location and reason for call, then a categorisation being applied as “in-scope” or “out of scope”. In scope calls were those which related to a true deteriorating patient episode, rather than a concern with care delivery or communication. Information provided to us showed 4 cases had been reported as ‘’in-scope” across the medical wards. Each month these calls are scrutinised and relevant detail entered onto a spreadsheet. Data is then uploaded to a template before being sent to the National team (NHSE) via the Business Intelligence Team.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients where they experienced difficulties, such as related to stroke or dementia.

We saw Deprivation of Liberty Safeguards (DoLS) were used where patients lacked capacity to consent to their treatment, to being on the ward, needed continuous supervision, and were not free to leave. Such measures were necessary, in their best interests, and the least restrictive option. Authorisations for DoLS were dated and contained expiry dates. All Band 5 staff and above were trained to apply the principle of the mental capacity act and when to apply a deprivation of liberty safeguard.

Patients who spoke with us confirmed the staff had discussed their needs, any limitations they had and what had brought them into hospital. They reported being made aware of any safety risks, such as falling, risks related to their presenting condition and treatment thereof.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Most wards in which patients received medical care were suitably organised, with a mixture of bay bed areas, single side rooms, shower and toilet facilities. However, Mary Anning Ward was being used differently to its usual set up, with a split between stroke provision and dementia care respectively. This was because there was construction of a new unit. Despite staff working with the temporary arrangement, we saw dementia friendly décor, with different paint to door frames, a dementia friendly clock and grab bars. On Maud Alexander Ward we found a smaller environment, which meant there was less room for storage of equipment. We noted too there was no fire escape signage on this ward. We escalated a broken lock on the Control of Substances Hazardous to Health (COSHH) and an unsecured room, which had chemical product accessible on the sideboard. The trust took immediate action, and the broken lock was rectified on the day the issue was highlighted.

Shower rooms were spacious and had non-slip flooring and ligature free call bells were provided in toilets and bathrooms. Call bells were at patient bedsides too. Accessibility aids were provided near toilets and there was a range of shower aids such as shower stools and commodes in use. There were no hoist devices available for staff to use, such as for getting a person off the floor if they fell. A lifting aid was held centrally with the clinical site managers and there was access to the equipment 24/7. A core number of staff were being trained in the use of the lifting aid to ensure that it was used correctly and maintained. Some staff told us there could be delays to the patient whilst waiting for a trained member of staff to help lifting. Staff were not aware of any plans to increase the number of staff trained in this manual handling device.

Separate clinical areas were available to staff, such as clean utility, sluice, linen storage and medicines rooms. All areas were secure access only. Non-clinical waste bins were placed in all areas, and these were used correctly.

On the Prince of Wales Ward, some patients would require technical procedures to be undertaken related to dialysis. In such cases the treatment was carried out in a designated clinical room, which was accessed via a security code. We saw this was well designed and equipped, with plenty of space, a clinical basin, equipment and stock storage and secure code access to a medicine cupboard.

The Endoscopy Unit was purpose built in 2017 and had 6 admission rooms, a resource room, 2 recovery areas, each with 4 spaces. Flooring within the Endoscopy Unit was suitable and found to be intact. All areas were suitable for use and managed safely.

Patient-Led Assessments of the Care Environment (PLACE) reported scores for the appearance and maintenance of the environment in 2024 was 99.21%. Patient-Led Assessments of the Care Environment are annual inspections in NHS-funded hospitals by staff and public "patient assessors".

Single use equipment items were readily available and stored in clinical rooms. Technical equipment used by nursing staff was readily available and items were subject to routine safety checks and servicing. Dates indicated when such checks had been carried out were attached to each item of equipment. Resuscitation equipment was seen on each ward area. This equipment was checked daily and a record completed by staff to show this action had been carried out. Staff maintained equipment well and kept it clean in between use. There was piped pure oxygen to the patient bed areas and some additional portable oxygen cylinders, which were stored safely and securely. Cylinders had expiry dates. There was no piped air at bedsides, which reflected good safety standards, minimising the risk of staff attaching breathing masks to air rather than oxygen. Fire aid devices were visible, stored safely and had expiry dates attached. There was a nominated fire warden on each ward.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Managers had calculated the number and grade of nurses and healthcare assistants required. They could adjust staffing levels daily to take account of case mix and activity and to ensure the safety of patients. Staffing levels in Endoscopy were good on the day of our assessment and staff were happy about staffing in this area. We saw staffing levels were displayed on wards, including actual numbers of qualified nurses and healthcare assistants and expected numbers per shift. The number of nurses and healthcare assistants matched this number on all shifts we were present for.

However, most nursing staff and healthcare assistants who spoke with us said staffing levels could be a challenge, and they felt they needed more. Some tasks took considerable time, which meant the staff member doing these tasks was not readily available to help others. When staffing levels were escalated to the senior leadership team, they found a response was often lacking. On Ilchester Ward, staff told us there had been a reduction in the number of nursing staff, which meant a nurse may be responsible for up to 9 patients. They said it could be difficult to meet the patients’ needs if they required 2 staff to assist them, and they could not have additional staff if the needs of the ward increased. The trust advised us that Ilchester Ward would have 5 registered nurses (RN) and 5 healthcare support workers (HCSW) per shift for a 33 bedded ward. This gave a planned ratio of 1:7 RNs excluding the nurse in charge, the supervisory ward leader and a clinical practice educator. The ward vacancy position at the time of inspection was 1.9 HCSW vacancies and 2.1 RNs whole time equivalent.

On Mary Anning and Maud Alexander Wards staff told us staffing was not “great”, saying weekends could be short staffed, due to sickness. Staff spoke about the difficulties they experienced if patients became challenging because of their dementia and trying to meet their needs at such a time. Patients who spoke with us said they felt there were enough staff to meet their needs, although some said how busy the ward staff were.

The trust advised us that Monday to Friday there was a ‘Matron of the Day’ (MOD) who held a bleep for escalations including staffing. The MOD reviewed all ward/department rosters and liaised with ward leaders and matron colleagues to mitigate staffing risks. There were twice daily strategic staffing meetings to approve use of excess hours, incentive payments and overtime as well and agency use. Staffing levels were determined by census data captured in an intelligence system known as ‘Allocate SafeCare’, together with professional judgement. Fill rates were reviewed at a monthly Safe Staffing Group and red flag reporting was captured in the revised Quality Report dashboard. For the months of December and January there were no red flag shifts reported for medical services.

Out of hours the process to escalate staffing matters was via the night sisters and clinical site managers who could escalate to the manager on call when authorisation for additional staff was required. Where individual patient requirement dictated, additional staff, including registered mental health nurses, additional shifts were added to rosters to supplement core staffing levels.

Information on staff vacancies for the medical services was provided to us. Full-time equivalent (FTE) nursing levels were above budget, meaning they had no vacancies. Allied health professionals had a vacancy rate of 7.22%, with a target of 116.02 and having 107.64 FTE. Healthcare assistants had a vacancy rate just below 16%, with a target of 218.63 FTE but having 183.75. The vacancy rate for doctors was 12.37%, 38.61 FTE against a target of 44.06.

Information reviewed reported that recruitment requests and change of establishment forms were being considered at weekly divisional meetings. Further information suggested that vacancy numbers were continuing to increase, in part due to a slowing of vacancy requests approval processes and some posts being held pending a wider administration and bed change review. There had also been some unexpected leavers due to new visa rules.

We were told a recent overseas recruitment campaign had been successful and these new staff members were being supported to adjust to their new country and workplace. Existing national staff were being trained in equal opportunities, race and cultural awareness to resolve any difficulties and perceived inequalities. There was an emphasis on the strength of the medical directorate staff compliment, and they had reduced reliance on agency. Daily meetings helped to gate-keep staffing and they tried to incentivise own staff before going to agency.

When needed, managers deployed agency and bank nursing staff to maintain safe staffing levels. Information provided to us showed only one agency consultant doctor had been paid in June 2025. Use of agency nursing had declined in August 2025, with the main use being on Ilchester and Fortuneswell Wards, covering sickness, maternity and vacancies, plus additional unfunded beds. However, agency use increased in September and October, before reducing in November 2025. There had been an increase in bank staff use, which reflected the reduction in agency in August 2025, with an increase through to October, before reducing in November 2025. There was some locum agency doctor cover for periods of strike activity.

There was adequate 24-hour medical cover, with doctors on duty at all times and on-call arrangements. Staff said they could get hold of medical staff when needed.

Staff had access to training in safety related subjects, with a completion target of 90% or above. We saw information which showed the completion rates for required training was at 89%. The lowest rate of 61% was for conflict resolution, which only became mandatory in December 2025, and the highest at 100%, was for preventing radicalisation. There was a well-structured electronic system for keeping oversight of training, including when it was coming up for a refresher.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Cleaning schedules were displayed on each ward and staff with cleaning responsibilities had the right equipment to undertake their duties in accordance with safety standards.Standards of cleaning were monitored through audit, and further through any reports received from the Patient Advice and Liaison Service (PALS), and through Patient-Led Assessments of the Care Environment (PLACE). The most recent PLACE scores for cleanliness were just below 100%. The medical ward audits for the past 4-months ranged from 94% to 99%. Patients who spoke with us told us they found the environment to be clean and that they saw cleaning staff regularly attend to the areas. We found wards to be visibly clean or in the process of having the routine cleaning carried out.

The Endoscopy Unit was visibly clean and suitable for use, having been prepared for patient activity on the day of our visit. The unit had been Joint Advisory Group (JAG) accredited, which included for the standards related to the environment and decontamination process.

Disposable curtains were arranged at each patient bed in bay areas. These were clean and dated with the day they were hung. Bed tables were generally clean. We checked several items of equipment aids and found these to be clean and fit for use.

Bed linen was changed regularly and staff used infection control precautions when handling and disposing of soiled linen, and other waste materials. Separate clearly marked bins were available in all areas. Staff had access to personal protective equipment (PPE) and we saw good use of such items.

Staff followed infection control principles, including handwashing. Clinical hand wash basins were placed near to patient bed areas and where needed, along with hand wash and decontamination agents and paper towels. These were stocked up regularly. Hand decontamination gels were near ward entries and were seen to be used by staff and visitors. Clinical waste bins, including those for sharp items were readily available and used correctly.

Isolation precaution signage was displayed on the entrance doors to single bedrooms, when needed. Staff were seen following safe practices before entering and after leaving the room. Members of the Infection Prevention Management (IPM) team did daily ward rounds to review the use of side rooms in use for isolation. They provided an update through the reporting system, so site managers and others were aware.

An annual summary of the IPM activity and status of the healthcare associated infections (HCAIs) showed the trust was meeting key standards and regulatory requirements for IPM over the reporting period, 2024-2025. The trust reported on hospital acquired infections, including E-Coli, which is a group of bacteria that can cause infections in your gut (GI tract), urinary tract and other parts of your body. They also reported on C-Diff (Clostridium difficile - a type of bacteria that can cause diarrhoea. It often affects people who have been taking antibiotics. Meticillin-resistant Staphylococcus aureus or MRSA was another infection reported on. This is a type of bacterium responsible for difficult-to-treat infections due to its resistance to many common antibiotics. Data was reported for the whole trust, rather than individual wards.

Staff were provided with training related to IPM. This included IPM Education Framework tier 3 training, which supported safe and effective care. There was face to face IPM education and training and the e-learning programme had been updated. In addition to training and education, staff had access to IPM policies and procedures. Polices were reviewed by the IPM team and specialities every 3 to 5 years, as indicated or sooner, if professional guidance changed.

Staff could access the Infection Prevention Management team. Wards also had link IPM staff, which helped in communicating information and having oversight of expected standards.

Within the Endosopy Unit, there was a formal process to register patients alongside the item of equipment used for their diagnostic procedure. This allowed accurate traceability of the endoscopes used and reduced the risk of endoscopes being used after the 3-hour expiry time.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

The service had safe systems for the safe handling of medicines; however, we saw that at times these were not always followed by staff. On Ilchester Ward we saw the medicines cupboards were left unlocked for ease of quick access, which meant access to medicines was not always restricted. Coded locks were used for the medicine’s cupboards, and some staff were not aware of these codes ever being changed. However, the cupboards were within secure medicine rooms, only accessible via a secure code.

Staffing levels in pharmacy meant the workload had to be carefully prioritised. Staff used a variety of data led, electronic sources to inform this prioritisation and to mitigate the risk of reduced staffing capacity. However, staff told us that at times this made it difficult to ensure patients medicines were optimised. For example, during our assessment the pharmacist covering the medical wards was also required to release chemotherapy due to short staffing in the aseptic unit. To manage this situation, they used a risk-based tool which gathered data about patients from their electronic prescribing system and identified the highest risk patients, for example those with Parkinson’s, to allow them to triage which patients they saw first.

Staff were able to access the Dorset Care Record to confirm details of patient’s medicines on admission. Staff told us this record was more detailed than the national Summary Care Record (which could also be accessed) and helped them get the most accurate information. Pharmacy set a target of 50% for medicines reconciliation within 48 hours of a patient’s admission. Medicines reconciliation is the process of accurately listing a person’s current medicines, at transitions of care or when their treatment changes. Audits since April 2025 showed this target of 50% was often not met. The pharmacy department was working to improve these results.

Hospital At Home was used to provide hospital level care to patients in their own homes with the view of preventing admissions and expediting discharge. This service had expanded rapidly over recent years but there had been no additional funding for pharmacy support to this service, which meant pharmacy staff had to cover this service without additional resource. We were told there were some discussions about additional staff resources, but no business case was in place as yet.

There was a policy to support inpatients to self-administer their medicines. An individual assessment of the safety of this for individual patients was required before self-administration started. We saw 2 patients self-administering their medicines who had not been assessed as safe to do so.

The medicines safety team investigated medicines incidents and undertook a wide-ranging program of medicines audits. We saw examples of how these led to changes in practice and improvements in patient safety.

An extensive medicines safety programme was available at the trust. A medicines safety nurse was embedded in the pharmacy medicines safety team. Staff told us this improved their ability to engage with nursing staff across the trust and make improvements to medicines administration practices. Staff also told us this post was very helpful as it brought a different professional perspective to medicines safety and improved the engagement of nursing staff across the trust in medicines safety issues.

The service had systems to ensure staff knew about medicines safety alerts and took action to ensure compliance with these alerts. There was also a system and process to ensure the ongoing compliance with medicines safety alerts issued by the National Patient Safety Agency. This included historical and current alerts. The medicines safety team also revisited historical medicines safety alerts and audited the ongoing compliance against these alerts.

Patients had an electronic medicine record, although some medicines were still on paper charts, such as insulin sliding scale. However, we saw placeholders for these paper prescriptions were included in the electronic record to prevent these medicines from being missed. This helped staff to have good oversight of each patient’s prescription, when medicines were required, the route to be given and for recording after taken or administration. We saw and heard staff follow correct procedures when preparing medicines, the safety checks before giving and the completion of the process. We found staff had access to the right equipment to support the delivery of medicines in a safe manner. This included syringe minders for intravenous medicines, purple syringes, diabetic syringes and nebulisers.

Emergency trolley checks were taking place. Items in the trolleys were present and in date. Fridge temperatures were monitored via a centralised system, which alerted in pharmacy if there were issues with temperatures of fridges. Ambient temperature monitoring was done in the same manner.

When needed, specialist input was available from teams including the pain team, Parkinsons team or end of life team. A ward-based dispensary area was available for pharmacy staff to dispense medicines from. This reduced the time for discharge prescriptions to be prepared as it meant they did not have to go down to the main pharmacy. Nursing staff told us it was useful having this area as they could usually find someone from pharmacy there if they needed their help or input.

Nursing staff in the discharge lounge told us there had been a huge improvement in the pharmacy support to this area over the last 2 years. Nurses felt the pharmacy service supported them well and worked hard to ensure medicines were ready for patients when they needed them. Nurses told us that at times of delay this was related to doctors not writing prescriptions in a timely manner.