Arrowe Park 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

At our last assessment we rated this key question requires improvement. At this assessment, the rating has remained requires improvement.

The service was in breach of legal regulations in relation to infection prevention and control, risk management, environment and equipment, and staffing levels. Staff did not always have the training and resources needed to manage risks effectively. Infection control processes were inconsistent. Staffing levels had improved, however did not always meet patient demand or acuity within the department. Training figures were below required compliance. Patients were frequently treated in unsuitable and unsafe areas, including corridors, with little privacy or dignity. However, staff responded appropriately to safeguarding concerns.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

We asked staff how learning was shared across the department. We were advised that there used to be an MDT safety huddle at the start of the shift but that had not happened recently (approximately the last 6 months or more) because of the building work. Staff said that there was no space for staff to gather as a whole team in the morning anymore and that staff now received their allocation, then had their area specific handovers. However, the trust advised that the service had a multifunctional room upstairs within the department to gather as a whole team.

Emails were sent to staff sharing information for both department and trust wide learning. For example, there was a current focus on rounding and skin checks in the department in response to incidents. A paper Situation, Background, Assessment, and Recommendation (SBAR) / rounding document had recently been introduced for ambulance / trolley patients; no work had taken place to assess the impact or improvement.

Staff advised that they reported incidents but did not always get a response. Staff said that when reporting incidents, they often received generic responses and that they were not clear how specific learning was consistently shared.

The top cause for incident reporting within the emergency department were for patients admitted to the ED with pressure ulcer / tissue viability concerns. Skin checks were part of the admission checks, and the patient safety checks within the department. Documentation of skin integrity and incident reporting were said to be an established process. The next highest reported incident in the severe / catastrophic category was the emergency department capacity. Processes and standard operating procedures (SOPs) were in place to support the department when volume exceeded capacity.

Data provided (reporting period not identified) highlighted a total of 3,967 incidents of which 2,319 were no harm incidents. Within the 3,967 incidents there were 1 fatal, 17 moderate, 2 severe, 618 low harm and 195 near miss incidents. The highest themes after admission with pressure ulcers were access, admission, transfer, and discharge – 561 (all low harm, no harm or near miss), medicine management - 409 (362 no harm), treatment / procedure / clinical care – 231 (1 fatal), and slip / trip / fall of patients – 231.

We requested and reviewed 3 recent patient safety incident investigation (PSII) reports. Patient safety incident investigations (PSIIs) were undertaken to identify new opportunities for learning and improvement. PSIIs focussed on improving healthcare systems; they do not look to blame individuals. One PSII report was provided following the assessment. The report was comprehensively completed and undertaken with multidisciplinary involvement. The learning, improvement and action plans were clearly identified. Findings were shared trustwide via safety bulletin.

The duty of candour requires registered providers and registered managers to act in an open and transparent way with people receiving care or treatment from them. We requested evidence of occasions when duty of candour (DoC) had been completed in the last 12 months in the emergency department. Figures showed that the DoC process was implemented on 11 occasions by the adult emergency department between 1 May 2024 and 30 May 2025, and 2 for the paediatrics emergency department for the same period

We scored the service as 2. The evidence showed some shortfalls. The service did not always establish and maintain safe systems of care. They made sure there was continuity of care, including when people moved between different services.

The attendance figures for May 2025 at Arrowe Park emergency department were 6,275 for walk in patients and 2,223 for ambulance arrival patients.

We were advised that the standard operating procedure (SOP) for streaming patients within Wirral University Teaching Hospital NHS Foundation Trust (WUTH) was currently under review. In place of this, the trust provided the streaming SOP for the Urgent Treatment Centre (UTC) developed by the local community NHS trust. Data showed 1,317 patients had streamed from the emergency care department to the urgent treatment centre in May 2025.

On arrival to the emergency department (ED) all patients were assessed by the triage nurse using the Manchester triage system. Patient locations were visible on the ED tracker board. Patients in escalation areas of the ED had observations completed in line with the trust NEWS2 policy, which was under review at the time of the assessment. If a patient deteriorated the patient was reassessed by the nurse or doctor looking after the patient and the NEWS2 policy and escalation process was followed. The Emergency Physician in Charge (EPIC) and shift leader were informed, and the patient would be moved to a higher acuity area or the resus room, if needed, for ongoing management. In the event of an emergency, the patient would be transferred immediately to resus whilst staff simultaneously informed the shift leader.

The temporary escalation spaces across the emergency department were the ambulance arrivals corridor which could hold 12 patients, x-ray corridor & ophthalmic recovery area which could hold 13 patients, and an area in the middle of initial assessment which could support 3-5 patients. Ambulance arrival and the x-ray corridor were utilised for patients that attended via ambulance and had been assessed by the ambulance triage nurse as suitable for corridor care. The initial assessment area was utilised for patients that had been assessed by the triage nurse from the waiting room as requiring additional treatment or closer observation.

We reviewed the SOP for the roles and responsibilities of the lead consultant / emergency physician in charge (EPIC). However, it was not recorded in a similar format to other trust SOPs, was not dated, ratified, and did not have a review date planned. The standard operating procedure for Management of Emergency Patients When Volume Exceeds Capacity was in draft at the time of the assessment.

At the time of the assessment there were a 3 key SOPs in draft which should provide significant guidance to staff for the safe systems and procedures of the emergency department. We were not assured that the 3 SOPs remained appropriate while under review / in draft, or that any amendments were embedded.

We requested that the trust provide the daily number of patients held on trolleys on the corridor for the 3 months prior to our assessment, including the ambulance arrival corridor. There were 5,559 patients cared for in the corridor area between February and April 2025.

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. 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.

There were 2 complex care and safeguarding practitioners in post as well as a disabilities nurse. They were leads for the Mental Capacity Act (MCA), Deprivation of Liberty Safeguard (DoLS) gatekeepers, who undertook LEDER (Learning from lives and deaths – People with a learning disability and autistic people) reviews, and attended safeguarding board meetings. There was a children’s named nurse in post for children and looked after children and a named doctor for children. The ED consultants held a dual role with the Integrated Care Board (ICB) for safeguarding. The trust held a joint tracker with Local Authority for initial health assessments for looked after children.

The trust provided a bespoke training package in line with national guidance but were in the process of moving to a national training package. The current training covered all aspects of safeguarding from level 1 to 3 for adults and children. Level 3 safeguarding training was delivered as a face to face courses. Safeguarding training had met the trust target at 90% across each division. The training included DoLs and MCA. Additional non mandatory sessions were provided for staff along with safeguarding 7-minute bulletins (updates).

Internal safeguarding referrals were responded to with an update or outcome, with updates held on the patient record and the record flagged for staff. Section 42 investigations were fed back to staff for learning during swarm huddles (a swarm is safety huddle carried out in a blame-free environment and while the incident is still fresh in everyone’s mind).

Staff were familiar with the referral process and who the safeguarding nurse was for the department. We were told that the safeguarding team were approachable. Staff felt the referral process ‘was easy’ and knew how to access the safeguarding policy, and who to ask for support if required.

Staff were able to give examples of recent safeguarding referrals for children and adults who had attended ED. We were advised that there was always duty cover out of hours for safeguarding advice within the department. Domestic violence questions had recently been added to the triage form, which helped detect safeguarding issues, however these were not mandatory.

Safeguarding mandatory training in the trust was a bespoke package – “Protecting Vulnerable People” (PVP) levels 1-4. PVP delivered the safeguarding mandatory training as set out in the Intercollegiate Safeguarding for Adults Roles and Competencies document. PVP also incorporated other aspects of mandatory training including PREVENT basic awareness (The Prevent duty - to help prevent the risk of people becoming terrorists or supporting terrorism’) and WRAP (Workshop Raising Awareness of Prevent), Mental Capacity Act, Domestic Abuse and Harmful Practices, Learning Disabilities, Children Looked After.

The Associate Director of Nursing for safeguarding was working in conjunction with the Head of Learning and the Learning and Vocational Development Manager to align to the national core skills training framework.

Safeguarding audits were completed for each area as part of benchmarking audits.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them.

Patients attending the emergency department had a falls risk assessment completed at the triage stage. Falls assessments also formed part of the patient safety check list. Information relating to patients identified at risk of falls were passed onto the nurse responsible for the patient’s care. Falls assessment compliance for April 2025 in ED was 86.8% from a review of 896 assessments. The compliance for March 2025 in ED was 83.1% from a review of 830 assessments, and February 2025 compliance was 81.5% from a review of 677 assessments reviewed. Results show a slight improvement each month, but figures remained below target.

The trust used a pressure care risk assessment to identify patients’ pressure care requirements in line with the wound management guidance recommendations. This specific risk assessment was introduced in April 2024 following a period of staff training, a policy update and information technology (IT) development within the patient administration system. The assessment compliance was monitored at admission and again at 7-days. All patients who attended the emergency department were reviewed in relation to pressure areas. Patients admitted via ambulance had a full skin inspection unless declined by the patient and this was recorded in the electronic patient record (EPR). Staff told us this was a challenge due to the corridor care and length of time patients spent on trolleys outside of bays.

Staff completed incident reports for all patients admitted into the department with pressure damage, with a description of damage and area. Pressure area assessment compliance for April 2025 was 88.8% from a review of 1,324 patients. Compliance for March 2025 was 85.9% from a review of 1,159 and February 2025 was 83.8% from review of 1,019 patients. Results show a slight improvement each month, but figures remained below target.

We requested compliance figures for patient intentional rounding for the last 3 months. We were informed that compliance with intentional rounding recording in the electronic patient record had been an area recognised as requiring improvement within ED. A paper rounding document had been introduced in 2025 to ensure visibility and allow senior nursing team real time oversight. While spot checks were undertaken, the paper document had not been reliably audited. There were plans to introduce this on a weekly basis and to report through the ED’s divisional quality board. There was no current policy for intentional rounding within the trust. A ‘task and finish’ group was set up in March 2025 to review the approach across the trust.

The trust advised that where appropriate patients presenting to the Emergency Department (ED) with mental health needs underwent a side-by-side triage process, jointly conducted by an ED nurse and a member of the Psychiatric Liaison team. During triage, the patient's presentation was assessed, and the appropriate RAG (Red, Amber, Green) rating was applied based on immediate needs and level of risk. This clinical information was documented within the local mental health trust electronic patient record and verbally communicated to the ED Nurse. Both trusts maintained their own records. We were advised that the trust staff used the Mental Health Fundamentals of Care documentation throughout the patients’ stay in ED, which included the level of observation required.

The trust provided a copy of the Mental Health fundamentals of care and environmental risk assessments for mental health. We found both included checklists including: ‘does the patient require 1:1 supervision?’ ‘Have clinical observations been undertaken and recorded as per plan? If not, this must be escalated to the shift leader.’ It was not clear from the information provided where the details of management plans would be documented or how frequently the fundamentals of care document would be completed. It was not clear from the information received how management plans are recorded. We observed good care and management of risk, but it was not well recorded.

We sampled 10 patients attending the ED with urgent mental health needs and saw that all patients were seen within one hour of referral by an appropriate mental health clinician and assessed in a timely manner. The longest wait time was 40 minutes from referral to when the patient was seen by the mental health liaison. However, we saw 5 mental health patients in the department, 2 were waiting for mental health beds in another trust. They had been waiting 75 hours and 46 hours.

We scored the service as 1. The evidence showed significant shortfalls. 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.

We found expired equipment in several areas of the ED including blood gas syringes, blood bottles, and thickening fluids. We also found thickeners which were not securely stored. Staff in ED told us there were repeated issues sourcing equipment including infusion pumps and air flow mattresses. The trust responded to the concerns raised and took immediate actions such as removal of the identified expired equipment, blood gas syringes, blood bottles and thickening fluid. Within ED, thickener storage was to be assessed dynamically in clinical practice. To assure safety a stock check of all equipment in ED was to take place.

The trust were aware of feedback from staff regarding sourcing equipment. During the assessment, the trust arranged for the Electro Bio-Medical Engineering (EBME) to work with the clinical teams to understand the additional equipment needs within the emergency department. Provision of additional infusion pumps was highlighted as a priority. The trust had awarded a contract for new air mattresses that would increase supply and availability of mattresses significantly.

We were informed that the resus trolleys had a full check on the 1st of each month when the trolley seal was broken to check contents, a daily equipment check undertaken, and cleanliness check with oversight from the co-ordinator took place. We reviewed resus trolley check data for the corridor April and May 2025, and the Children’s ED March and April 2025. Resus trolley checks for the corridor in April 2025 showed that when items were identified as missing, they were not restocked and remained missing for 6 consecutive days (checks). We also reviewed 3 months records of resus trolley checks for the CDU trolley, and it is not clear how the department were assured these checks were regularly taking place or that stock was in date.

We observed trolleys in poor condition on the eye corridor, and patients lying on trolleys without sheets.

We requested environmental audits and equipment audits for ED such as waste management, privacy curtains, equipment checks and any action plans and were advised environmental audits are carried out monthly and included all areas within the department. We reviewed 6 audits which were completed on a monthly basis. The audits showed repeat issues for ‘Random review of equipment is clean and has current (I am clean) stickers visible’ and ‘Random review of commodes are clean and labelled appropriately’ for 4 out of 6 months. We also saw action taken when a staff member did not conform to the trust uniform policy.

Records showed that portable appliance testing (PAT) was last carried out in November 2023. The Electricity at Work Regulations 1989 required that any electrical equipment that had the potential to cause injury was maintained in a safe condition. However, the regulations did not specify what needed to be done, by whom or how frequently (i.e. they don't make inspection or testing of electrical appliances a legal requirement, nor do they make it a legal requirement to undertake this annually). Electrical installations were maintained and tested (where required) by the estates department. Data showed that electrical safety testing of equipment was completed at the same time as the servicing of that piece of equipment. Evidence of this testing was then downloaded from the testing devices uploaded onto the trust equipment database.

During the assessment we were advised that the equipment library was not managed, and staff were required to leave a message which took time and caused delays. We observed it take 2 hours to find a pump for infusion for a patient; this was said to delay treatment and was a poor use of staff time. We were also advised that it could be difficult to obtain pressure mattresses and syringe drivers for end of life care patients arriving in the ED. This often required escalation to the hospital co-ordinator.

The children’s ED was observed as a nice environment for children and appropriately decorated. We saw that children walked through both adult waiting rooms to get to children's ED, but then all areas were separate. There was no separate entrance for children to ensure security and access to keep children safe. There was a considerable distance between the children's ED to resus, if needed. This layout was imminently due to change as part of the building construction, which was underway during the assessment process.

The trust had three mental health assessment rooms. All rooms were in use at the time of the assessment. There was a large window for easy observation of the patient. There was support provided to one patient who was asleep. There was a clinical support worker working within the area who could see into room one. The rooms appeared dimly lit due to the patient sleeping, minimally furnished and with one entrance/exit which was not RCEM Psychiatric Assessment Room compliant. Room one was the only room with an en-suite.

There was a fire safety policy in place which was published March 2025 and appeared both detailed and appropriate in content.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled, and experienced staff. They did not always make sure staff received effective support, supervision, and development. They did not always work together well to provide safe care that met people’s individual needs.

The trust-wide Nursing Safe Staffing and Escalation policy was currently under review. A corporate, medical & local induction policy was in place, approved on 12 March 2025 and due for review 12 March 2028.

There was a Trust Establishment Review standard operating procedure (SOP) and a Board-approved full business case for ED staffing (2024) which detailed the staffing requirement for the department and investment made to increase the nursing and clinical support worker establishment.

The trust advised that demand on the ED had experienced significant change during and post COVID-19 with an increasing level of attendances and presentation. Over the last two years there had been two amendments made to the nursing establishment to accommodate new areas that were opened (Ambulance Arrival Zone) and in line with the national request to support ambulance handover performance. ED was established and funded for 17 registered nurses (RN) and 8 care support workers per shift. Attendances had increased by 7% in the last three years and could often a surge with up to 10% of the day’s attendances arriving in one hour, increasing the pressure on maintaining triage within 15 minutes. There had also been an increase in the acuity of patients attending the department and this was supported by the increase in ambulances attendances that has been experienced over the last 2 years.

The trust advised that in July 2024 the emergency department utilised the Emergency Department Safer Nursing Care Tool (EDSNCT) to complete its acuity and dependency review. The primary outcome of EDSNCT recommended introducing a staffing model that was aligned to the department’s increased periods of activity. The trust had received a similar recommendation from NHS England’s Emergency Care Improvement Support Team (ECIST). A business case to support this proposal was approved by trust board and had increased the funded establishment by 44.4WTE. Recruitment to these additional RN and CSW posts was ongoing at the time of our assessment.

The number of staff in the ED varied throughout the day and night to match the peaks in demand with between 21-23 RNs and a total of 7 x band 2 staff to provide care and intentionally round the department throughout the 24 hour period and 5 x band 3 to undertake rapid investigations to ensure when the senior review occurs the required information is available for decision making to occur.

However, the most consistent message we have received from staff working in the trust was that services did not have enough staff. In ED we heard that staff had stopped reporting incidents of short staffing because there was a limited response. Staff were concerned about the increase in ratios of nursing staff to patients which had increased from 1 to 4 to 1 to 6 in the corridor area. Staff stated that services were reliant on temporary staffing to provide cover.

Rotas we reviewed showed staff were working considerable numbers of consecutive shifts as both regular and bank staff. We observed nursing staff being left with high patient ratios whilst covering breaks.

Staff were redeployed from other areas across the trust following escalation through the trust’s staffing meetings 3 times a day, as per the trust’s safe staffing and escalation policy which was under review during the period of the on site assessment. The draft policy was awaiting approval. Whilst there was a higher than optimum proportion of temporary staff utilised to achieve the fill rates, this was deemed by the trust to be safe for the following reasons:

• Following an establishment review process in 2024, a business case for ED nurse staffing was approved at Board.
• This funded a significant increase in both Registered Nurse and Clinical Support Worker posts, to ensure staffing during periods of escalation was sufficient to safely staff the department.
• The trust had been actively recruiting to these posts but, as is the case nationally, RN vacancies were predominantly filled by newly qualified nurses. All of the RN vacancies had been recruited to with start dates staggered until September 2025.
• In the interim, the trust recognised the need to support safe staffing through the use of NHSP (NHS Professionals) staff.
• There was a designated ‘ED’ code within NHSP and in the first instance, vacant shifts were filled by staff (often ED substantive staff) with this code.

Staff in ED told us that there had been reductions in medical staffing numbers including locum cover within the last six months. Consultant numbers met Royal College of Emergency Medicine (RCEM) guidance. Based on the number of ED attendances for the trust, RCEM guidance recommended a minimum of 30 WTE senior decision makers. The trust stated that they had achieved the RCEM standard by the following: 14.85 WTE consultants, 1.0 WTE specialist doctor 14.77 WTE registrars. This totalled a minimum threshold of 30.62 WTE. There was a business case for two additional consultants being considered on 28 May 2025 for approval by the finance board sub-committee.

The ED resident doctors fill rate for vacant ED shifts for the last 3 months was 88%. The ED had consultant presence on site 16 hours per day seven days per week. All requests for cover of on-call consultant gaps for the last 3 months were filled. Nursing fill rates had remained steady. Data highlighted that there were 10 registered nurse vacancies, 20 care support worker vacancies and 6 registered nurses on maternity leave. The registered nursing fill average was 94% with care support worker fill rates of 86%. The ED allied health professional fill rates for April 2025 was 77% for registered staff. There was 1 children’s ED registered nurse vacancy.

The Emergency Nurse Practitioner (ENP) provision was provided by a team of 7 ENPs (1 currently absent from work) who operated a 7 day service standard times of 8.30am to 10pm. Where possible they had 2 ENP on shift but that was not always the case. There was no direct doctor support but the ENPs had a positive relationship with senior doctors in the main ED should they require any additional advice or guidance.

The medical staffing for children’s ED was covered within the ED rota. The number of doctors including consultants within the Children’s ED (CED) was decided by the EPIC (emergency physician in charge) at the start of the shift. The decision was based on demand and acuity in ED and CED. It was reviewed throughout the shift and changed based on escalation when need changed. There was no dedicated children’s ED therapy resource. Therapy services were provided as required. The compliance for Paediatric Immediate Life Support (PLS) training was 83.4% for nursing staff. Advanced Paediatric Life Support (APLS) compliance figures were 90% for nursing staff and for medical 72.7% staff.

In the 3 months from February to April 2025 the percentage of shifts filled by NHSP bank nurses was 24% for day shift and 44% for night shift in February 2025. It was 23% for day shift and 53% for night shift in March 2025. Both months were over the target 20% maximum bank shift fill rate. April 2025 figures had improved with 14% dayshift and 16% nightshift usage of NHSP bank nurses used to fill ED shifts. The figures for CSW cover over the same period and same shifts were worse, with the average shift fill rate of bank staff being 43%.

The emergency department did not use agency locums. The trust used a collaborative bank approach to fill resident doctor gaps. This enabled suitably experienced Lead Employer doctors and trust employed doctors to apply to fill gaps in the rotas. Data showed that between February and April 2025 there were 3,241 shifts which required bank medical staff fulfilment.

Staff sickness rates for ED medical staff full time equivalent (FTE) for the last 3 months was 8% in February, 6.7% in March and 4.6% in April 2025. Nursing staff FTE figures for the same period were 6.3% in February, 3.5% in March and 2.9% in April 2025, both indicating an improving trajectory.

There were 46 nursing incident reports raising concerns about the number and skill mix of staff in the emergency department between November 2024 and April 2025. There were 5 incidents reported between November 2024 and May 2025 for the lack of medical cover, 18 incidents for the lack of suitably trained / skilled staff and 11 incidents for staffing levels not meeting national guidance. Staff did not feel that the staffing levels were adequate as there were times staff members had to leave the area to take patients to other departments, such as x-ray.

The appraisal compliance rates for medical staff in the ED was 78.8% and ED nursing staff compliance was 71.7%. There was a 100% compliance rate with Children’s ED nurse appraisals.

We reviewed the Mandatory Training policy which was in date and due for review 24 July 2027. The current mandatory training compliance data broken down by staff roles showed the following against a trust target of 90%. Mandatory training compliance for the acute care division overall was 87.17%. However, when broken down by role specific and training specific, compliance was variable.

Medical Staff training compliance was as follows: Infection Control (Level 2): 60.6%; PVP (Level 4): 78.8%; Advanced paediatric life support: 72.7%, and Advanced trauma life support: 54.1%. All against a target of 90%.

Nursing staff training compliance was as follows: Infection Control (Level 2): 78.5%, PVP (Level 3): 100%, PVP (Level 4): 90.2%, Advanced life support: 86.8%, and Advanced paediatric life support: 90%. All against a target of 90%.

Training figures provided for the Children’s ED were as follows against a 90% trust target: Advanced Paediatric Life Support (APLS) band 6 nursing staff: 100%, Protecting vulnerable people (level’s 1-4): 100%, Manchester triage training: 100%, Children’s nurse competency booklet: 95.2%, and Safer use of medicines: 100%.

The Oliver McGowan mandatory training on learning disability and autism completion rates were 71.6% against trust target of 90%.

As part of the Autism awareness month in April the trust invited external charities to provide support with additional training for staff. On 3 April 2025, the Brain Charity provided a 2hr session on Neurodiversity awareness to 27 members of the trust staff. On 25 April 2025 Wirral Autism Together provided a 3hr ‘Autism Acceptance Awareness’ session to 75 members of trust staff. The session was co-produced and co-delivered by experts with lived experience along with Wirral Autism Together staff. The trust has commissioned 200 places to be delivered throughout 2025 with 57 nurses and Allied Health Professionals trained so far.

Mental Health and Dementia Training compliance figures were 95.52% at the time of the assessment. In addition to this, Dementia UK approved training was provided by local representatives of a national charity entitled ‘Living with dementia.’ This one-day course was delivered by experts and individuals with dementia and their carer’s.

We scored the service as 1. The evidence showed significant shortfalls. 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.

We observed staff were not always bare below the elbow in line with the trust’s guidance. Staff were observed to wear watches, long sleeves, jewellery, and / or have painted nails. We also observed staff disconnecting IV lines without gloves, and staff wearing gloves when not clinically indicated. We escalated our concerns to leaders, and immediate actions were launched but fully implemented or embedded at the time of assessment. There was a leadership walkaround to assure standards of bare below the elbow, standards of dress policy were circulated to all doctors working within ED, reiterating the expected trust standard, the consultant team within ED were to monitor compliance on a daily basis and there was enhanced visibility of the Infection Prevention and Control Team (IPC) team. In addition, the following actions would be conducted: increased frequency of bare below the elbow audits / observations in practice, and use of the ward accreditation process to enhance the IPC audit programme.

The results the most recent Sepsis audit were not available unit August 2025. The trust were planning an upgrade to the electronic Sepsis pathway that would provide live sepsis data (rather than the current manual retrospective audits). This was due to go live during Quarter 4 in this financial year.

Hand hygiene compliance and embedded action plan dated May 2025 stated daily audits should be undertaken until compliance reached above 90% compliance. Current hand hygiene audits for April 2025 across the ED footprint compliance was 80% for CDU 80%, 11% for ED majors (7 – 24) and RCA (reverse cohort area), 20% for ED major (1 – 6) and ambulance arrival zone (AAZ) and 33.3% for ED resus. These figures were much lower than the trust target of 90% and did not comply with the trust action plan. The figures for May 2025 appeared incomplete and have not been referenced.

We requested the last 3 months infection control audits for cleanliness of environment and equipment. We found that ED divisional scores for IPC audits were 79.8% January 2025, 95.3% in February 2025 and 87.5% March 2025. The trust target of 90% was not achieved.

IPC training compliance for medical staff Infection Control (level 2) achieved 60.61% and nursing staff Infection Control (level 2) achieved 78.46%. The trust target of 90% was not achieved.

The IPC risk rating for the corridor escalation areas was rated high by the trust. There was a risk that patient care would be compromised due to the need to be cared for in an escalation area such as ED corridors or the middle of initial assessment. This is due to poor egress onto wards as a result of the number of patients who do not meet the criteria to reside and the lack of community provision. This could compromise the ability to follow correct IPC procedures especially on the main hospital corridor. Clinical waste bins were provided in the corridor areas to ensure that used equipment was disposed of at the correct time and in the correct way. There were additional controls in place.

The trust had adopted the National Infection Prevention and Control Manual (NIPCM) for all areas of the trust, as a result the ED did not have its own Infection Prevention and Control policy. The NIPCM is an evidence-based practice manual for all those involved in care provision in England. This manual replaces the following trust policies: Hand Hygiene policy and Standard Precautions policy.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. They did not always involve people in planning.

We were told the pharmacy team had developed a tool to support staff to identify if patients/people attending the department were taking a medicine classed as a ‘critical’ medicine. A critical medicine is a medicine that should not be omitted or delayed. The pharmacy team within the department would prioritise the completion of a medicines reconciliation for people taking critical medicines. A process was in place to support staff to access critical medicines from the pharmacy in a timely manner. An audit completed November 2023, showed 83% of critical medicines were prescribed correctly. However, only “55% of critical medicines were prescribed and administered correctly on time”. A further audit had not been completed to show if actions had been taken and if there had been any improvements made.

Staff completion of medicines management mandatory training was 60%. This did not meet the trust target of 90%.

Clinical pharmacy support was available in the department Monday to Friday. However, the pharmacy support available was not always as rostered. The pharmacy team support with the completion of drug histories and medicines reconciliation in the department. The technology used in the department did not support pharmacy staff to easily identify people who needed to be prioritised for a medicine reconciliation.

Staff stored medicines and controlled stationery securely. Controlled drugs had a stock check completed daily. The temperature of medicines storage areas were monitored constantly.

The carer of a person who was attending the urgent and emergency department told us they had had an amazing experience in the department and all the staff had been amazing.