The York Hospital

On this page

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

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

The service was in breach of legal regulations in relation to premises and equipment as it was not always secure and suitable for the purpose it was being used for. It was in breach of the legal regulation safe care and treatment as it was not always assessing the risk to the health and safety of patients and ensuring infection, prevention and control standards were followed. The service was also in breach of the legal regulation in relation to staffing, as staff were not receiving all the training required, especially medical staff. The service was in breach of the legal regulation relating to good governance as the service was not always ensuring that patient information was kept secure and there was an accurate and complete record.

We looked for evidence that patients were protected from abuse and avoidable harm. We assessed eight quality statements.

Incidents were reported by staff through effective systems and staff were aware of lessons learnt and improvement from investigations were identified. There were systems in place to keep patients safe and staff were aware of how to ensure patients were safeguarded from abuse, however the level of safeguarding training for staff was not aligned to national guidance.

The hospital was overall visibly clean, but staff did not always follow good hand hygiene guidance. Cleaning chemicals and oxygen had been left out in an unlocked room or not secured which presented a risk to patients and there were record trolleys and areas containing sharp instruments that were not locked and had been left unattended. Records we looked at were still not always fully documented and some risk assessments were still not always completed.

There were systems in place to manage the safe administration and prescribing of medication and staff attended mandatory and required training courses but compliance rates for some subjects were still below the trust target. Compliance rates for medical staff mandatory and required learning were still below the trust target in most subjects. The number of staff receiving an annual appraisal had improved.

There were still some staff vacancies and there were still wards and shifts where staffing levels were not overall sufficient to meet the needs of patients, but actions were in place to address this.

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.

The service was working to embed a culture of safety and continuous improvement, learning from events and incidents that had either put people and staff at risk of harm, or that had caused them harm. Senior leaders had clear aspirations and a commitment to creating a learning culture.

The service had recently implemented the Patient Safety Incident Response Framework (PSIRF) and staff told us that they were looking at the best way to use the framework to identify learning and get full engagement from clinical staff. There was a weekly safety brief informing staff of key alerts /issues and learning across the trust as well as a daily incident update to all senior managers and directors.

Learning from incidents was cascaded further to staff either through meetings or safety huddles as well as patient safety bulletins. However, whilst staff we spoke with could tell us about the process for reporting incidents and felt confident to raise concerns and report incidents and received feedback and learning relevant to their area of work, they did not always receive feedback on learning from other areas.

Staff reported incidents via the electronic incident reporting system and we saw that actions taken during investigations was also recorded to help inform learning. Between October 2024 and December 2024 there had been a total of 569 incidents reported for medical care services which indicated a good reporting culture.

Patients and those close to them knew how to raise concerns or make a complaint. There was a system in place to review themes and highlight any areas to escalate to the trust board. We reviewed several complaints and saw that learning had taken place and actions put in place. An example of learning included developing an improved communication poster and card to facilitate improved communication with patients and families regarding discharge planning and piloting bedside handover to facilitate effective communication.

We saw examples of where patients or relatives had shared their experiences with staff in ward meetings or at trust board meetings to support learning. A patient safety partner was also being recruited within the service, this role aimed to involve patients, carers or members of the public to support and contribute to learning from incidents to improve patient safety.

The service had in place systems and processes to identify and manage risk before safety events happened. For example, a multidisciplinary approach, aligned to PSIRF was used to review mortality and morbidity monthly. There was also an established team of medical examiners who carried out review of deaths that occurred in the hospital to help identify any learning.

All in-patient deaths were reviewed by a consultant within an expected timeframe of 4 weeks, with learning from mortality review discussed at department governance meetings and a quarterly report on learning from mortality reviews. However, we were told that due to demands on the service they felt this had impacted on finding resources to investigate patient deaths. This issue had been raised with executives who had expressed an ethos of ‘listening and trying to make change’ within the service.

Senior staff were aware of their responsibilities relating to Duty of Candour legislation.

However, healthcare assistants we spoke with were unable to tell us about Duty of Candour. The trust had a Duty of Candour process in place to ensure that people had been appropriately informed of an incident and the actions that had been taken to prevent recurrence. The aim of the Duty of Candour regulation is to ensure trusts are open and transparent with people who use services and inform and apologise to them when things go wrong with their care and treatment.

The service did not always work well with patients to establish and maintain safe systems of care. They did not always manage or monitor patients’ safety.

There were pathways into services provided by medical care, for example frailty same day emergency care and medical same day emergency care. These included referrals directly from the emergency department or the ambulance services. There were a set of criteria for staff to follow to ensure that patients were referred appropriately and safely. However, staff told us and gave examples that there had been occasions when an inappropriate referral had been made without a medical review. This meant there was a risk that care may not be provided in a timely way. Following the assessment, senior leaders told us that this was addressed through pathway reinforcement.

At the time of the assessment, there was a draft standard operating procedure for the clinical and operational management of the acute medical unit. This outlined the role and function of the unit and provided clarity on pathways and access criteria, for example, staffing levels, morning handover, and timely medical reviews. This was part of the hospital transformation programme. The acute medical unit provided assessment, investigation and treatment for acutely unwell patients.

The trust had in place an electronic patient record that all services used. The clinical notes operate as a summary contemporaneous record but some elements of nursing care were still recorded on paper. For example, skin integrity and care plan, catheter care plan and fluid balance charts. When patients were transferred to another ward all paper documentation followed the patient as part of their clinical record. When patients were discharged all paper documentation was scanned and uploaded onto the electronic record.

However, the information needed to deliver safe care and treatment was not always available to relevant staff in a timely and accessible way. Nursing and medical records were not always completed in line with national guidance. Staff told us it could be very difficult to find medical records, we observed multiple staff trying to use the same records and spending time looking for patient records.

The service undertook regular medical records and documentation audits. We reviewed the information for 2024 and found these were all above the target of 85%. Where there were some shortfalls in some of the standards, actions to improve had been identified although the action being assigned to a person was not always identified. We were told that a trust action had been put in place to improve this. However, this was not consistent with what we found.

A set of medical records we reviewed was incomplete with patient identifiable details missing, allergies and sensitivities recorded but illegible. On another ward multiple pages of medical documentation reviewed within a patient folder did not include patient identifiable information. This meant there was a risk not all important information would be available when required.

On the frailty assessment unit, we found patients notes that were in an unlocked trolley and open in a corridor which was accessible to the public and out of line of sight of staff. The records contained patient identifiable information. On ward 34 we observed patient case notes were kept in an unlocked trolley in the main corridor and away from the staff base where staff would have been able to ensure these were not accessed, amended or destroyed by those not authorised to do so.

We also saw a computer on ward 34 left unlocked whilst staff left the corridor and on ward 12, which during our assessment was opened as a temporary ward to support capacity, a laptop was left unsupervised and unlocked in the medicines preparation room with patient information visible and access to all records. The door to the room had been left open and there was no staff in the room or nearby corridor. This was accessible to both patients and the public.

On ward 22 (Acute Medical Unit) we saw a patient care plan attached to the door of a bay which had barrier nursing precautions in place. The record included multiple types of personal identifiable information and was visible to the public close to the entrance of the ward. When escalated to senior staff it was removed. It was unclear what steps were taken to inform the patient this had occurred.

The service had commenced the implementation of a new electronic patient record which was central to the clinical digital systems to improve record keeping.

The service undertook a range of health and safety risk assessments, for example, fire, violence and aggression and manual handling. These were done for each ward and department and were reviewed annually. At the time of the assessment, the manual handling risk assessments were unable to be located and there was no central record. However, since the assessment we saw evidence that these had now been completed. We also noted from review of the evidence provided that there were some areas which had a violence and aggression risk assessment that was overdue for review, for example Ward 21 and the acute admissions unit.

Pathways of care were not always effective in maintaining patients' continuity of care along their journey. At the time of our assessment, the service was using a continuous flow model, which included caring for patients in the corridors and in chairs whilst waiting for a bed on the ward to become available. Since the assessment senior leaders told us that there was clinical and operational lead oversight of these patients.

There were acute clinical care patient pathways to help with the flow throughout the hospital. This meant that patients were often moved through different areas for their care for example, emergency department to assessment areas and between wards. The trust reported that to balance the risk and as part of their continuous flow model, the first move of patients to the wards was to be completed by 9.30 am which meant moves commenced early in the morning which we observed happening before 8 am.

Many patients we spoke with had been moved multiple times during their admissions and were not always sure why. Patients told us this had been disorientating.

Leaders told us that the continuous flow model had caused some additional stress on clinical teams and that the communication about the model could have been improved for both staff and patients.

Following the assessment, we were told the trust was in the process of revisiting the continuous flow procedure and guidelines to re-emphasise the importance of effective communication with patients and improve the patient experience. We were also told that the trust was going to introduce wallet size cards for patients and families which would contain details of the ward manager to contact if they had any questions. The trust was also going to be piloting bedside handovers so patients and their families could be involved in the discussions and improve communication.

There was a strong understanding of safeguarding and how to take appropriate action. However, we were not fully assured that staff were supported to understand safeguarding at the correct level to keep patients safe from abuse and neglect.

Safeguarding policies and procedures were in place and staff knew how to refer a safeguarding issue to protect adults and children from abuse. The trust had a safeguarding team which provided guidance and staff had access to advice out of hours and at weekends. The policies contained relevant contact details for raising a safeguarding concern. We observed on the wards information signposting staff to the safeguarding team and policies were displayed in ward areas.

At the time of our assessment, the trust did not have a named nurse for children in care or a named nurse for safeguarding adults and currently this work was being covered by the safeguarding team.

The safeguarding policy did not outline the specific level of safeguarding training that staff needed to undertake in line with national guidance, however on reviewing the training for staff, staff undertook safeguarding level 1 and level 2 training. However, there did not appear to be any level 3 training completed from the information that was provided to us, which was not in line with national guidance for staff that require this level of training. We reviewed the training compliance for medical staff and found that whilst this had improved from the last assessment it was still below the trust target. Safeguarding adults level 2 compliance rate was 77% and safeguarding children level 2 was 76%. Staff did undertake Prevent training both at basic and level 3 training compliance was 79%.Prevent is a national programme that aims to stop people from becoming terrorists or supporting terrorism.

Leaders told us that domestic abuse was one of the concerns raised with the safeguarding team. In response to these concerns a domestic abuse practitioner (DAP) had been introduced who helped educate and support staff on how to recognise and care for patients suffering from domestic abuse.

Each day the safeguarding team reviewed any 16- to 17-year-old patients on adult wards. A standard operating procedure had recently been developed to support these reviews.

Safeguarding staff liaised with social care services and provided additional support for children who were under the Court of Protection. Staff told us that this work on the safeguarding of children on adults' wards was starting to embed and had a positive impact.

Staff had understanding of procedures relating to the Deprivation of Liberty Safeguards (DoLs) which are part of the Mental Capacity Act 2005. They aimed to make sure that people in hospital were looked after in a way that did not inappropriately restrict their freedom and was only done when it was in the best interest of the person and there was no other way to look after them. This included people who may lack capacity. We saw examples of DoLs paperwork completed fully and accurately.

Deprivation of Liberty Safeguards were monitored and although there were challenges in working with 3 local authorities and their different processes, staff worked well with the local authorities to maintain oversight of any applications.

The trust had recently moved onto a digital system to complete mental capacity assessments which had improved assurance around the completion of capacity assessments in line with the Mental Capacity Act 2005. Further education was being rolled out to staff by the safeguarding team and the new Mental Capacity Act educators, to improve decision makers in completing capacity assessment.

Whilst there was good recognition and escalation of the deteriorating patient, risks to patients were not always assessed and their safety monitored and managed, so patients were supported to stay safe.

Upon admission to wards, staff carried out risk assessments to identify patients at risk of harm. Patients at high risk were placed on care pathways and care plans were put in place to ensure they received the right level of care. The risk assessments included falls, pressure ulcers and nutrition. We reviewed care records and observed that risk assessments for these areas had been completed.

A policy was in place to support staff in the management of pressure related skin damage. There were also continence screening and assessment tools in place.

Staff completed fluid balance charts and food charts to document a patient's fluid and food input and output within a 24-hour period. This information was used to inform clinical decisions. However, we reviewed 3 patients notes on ward 22 (AMU) and found that the fluid balance charts and food charts were incomplete. One of these patients was also on intravenous fluids. We also saw in one patient’s notes on ward 12, which during our assessment was open as a temporary ward to support capacity, there was a history of dehydration and the fluid balance charts were incomplete. We noted that following a review of a death earlier in the year on an elderly ward one of the actions was ‘to work harder on documenting fluid intake especially if patient has poor oral intake’. The action was for oral fluid intake to be better monitored and documented. This meant there was a risk that not all relevant information was available to inform a clinical decision.

In line with National Institute for Health and Care Excellence (NICE) guidance, NG89, Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism all patients should be risk assessed on admission to hospital for venous thromboembolism(VTE). This should be as soon as possible after admission to hospital or by the time of the first consultant review. On review of information provided by the trust we found that compliance levels across medical services in the trust was low with an average of 19.5% risk assessments completed over a 12 month period. NICE guidance says all patients (at least 95%) should be assessed on admission to identify those who are at increased risk of VTE. VTE is a condition that occurs when a blood clot forms in a vein.

The same NICE guidance states that for patients who require anticoagulation, it should be prescribed and administered within 14 hours of admission. Hospital data showed varied compliance. For example, in March 2024 across the non-surgical wards an average of 63% being prescribed and of those, 82% being administered within 14 hours. Anticoagulants are medicines that help prevent blood clots. This meant there was a potential risk of harm as VTE assessment and management was not consistent or in line with national guidance.

The trust recognised that compliance with the assessment and management of VTEs needed to improve. We were told by senior leaders that the trust was looking to engage more ward-based clinicians, and those who have undertaken quality improvement projects in this area. The VTE Group would be continuing to review the data and have oversight. In addition, it was hoped the introduction of a new electronic system in 2026 would provide an opportunity for change.

The management of patient falls was a focus and staff received training to risk assess and mitigate the risk of patients having falls. In addition, there was a drive to increase lying and standing blood pressure monitoring for all patients aged over 65 or those at increased risk of falls.

The National Early Warning Score 2 tool (NEWS2) was used throughout the trust to alert staff if a patient’s condition was deteriorating. This was a basic set of observations such as respiratory rate, temperature, blood pressure and pain score used to alert staff to any changes in a patient’s condition. There was guidance for staff to follow to help inform what to do if a patient's condition was deteriorating. There was a critical care outreach team who provided support for patients whose NEWS2 was above a certain level (a score of 7 or above).

There had been a recent review of the recognition and escalation of the deteriorating patient to identify any new opportunities for learning and improvement. There were some areas of improvement identified, for example, education for staff, culture and the use of the blood gas machine. An action plan had been developed with people responsible for the action and timeframes for completion.

From information we reviewed there had been an improving trajectory from 83% to 89% of observations being taken on time between November 2024 and December 2024. The critical care outreach team had oversight of all patients NEWS2 scores and there were daily ward rounds to visit the acute wards and ward 34 to proactively check for deteriorating patients and provide staff support.

Patient records we reviewed contained a documented medical review for the majority of days during the admission including multiple days where the patient was reviewed multiple times in line with their high NEWS2 scores.

The trust provided training on the deteriorating patient though acute illness recognition and assessment days for registered nurses and healthcare assistants. There was also training available for junior doctors. We were told that the new electronic patient record being implemented would improve escalation through automated notification of when observations were due to be taken.

There was an initiative run by the critical care outreach team as part of national guidance and Martha's rule. Patients or loved ones could call a 24-hour helpline with concerns about themselves or relatives who they felt were deteriorating. Relatives were often able to more quickly identify if there was something wrong with a person they loved than staff, so this was a mechanism by which they could enhance care. People were encouraged to speak to medical and nursing team on the ward prior to calling the helpline for advice but the initiative provided a mechanism for people who were concerned about themselves or a patient to escalate this.

Staff completed enhanced care assessments for patients who needed 15-minute observations when required due to increased risk of harm.

The service did not always detect and control potential risks in the care environment and make sure equipment and facilities supported the delivery of safe care and always meet patient needs.

To maintain the security of patients, visitors were required to use the intercom system outside wards to identify themselves on arrival before they were able to access the ward and staff had access codes.

Each clinical area had resuscitation equipment readily available. There were daily systems in place to ensure it was checked and ready for use. Records indicated that daily checks of the equipment had taken place on the wards we visited.

We found on ward 32 that an allocated bed space was cramped and bed curtains were very close to the bed, which the patient told us led them to feeling claustrophobic at times. We observed that it would also be difficult to get emergency resuscitation equipment around the bed should it be needed. On checking procedures for additional bed spaces this bay was allocated for use with a chair only, however, we observed that a bed had been used.

Staff from multiple areas told us they did not feel able to deliver safe and dignified care to patients in overcrowded environments where additional beds or chairs had been added to existing bays. They told us there had been an incident when they had not been able to get a resuscitation trolley into a bay due to space restrictions. This meant there was a risk that patients may not be treated in a timely way in an emergency.

We observed and were told by senior staff that Ward 12 did not have a defibrillator or moving and handling equipment, including a hoist, and this equipment was shared by other surrounding wards. There were safety risks associated with timely availability of equipment in an emergency, and with negative impact on patients' dignity and experience should moving and handling equipment not be available. During our assessment this ward was open as a temporary ward to support capacity. However, senior leaders told us that the ward was decommissioned shortly after the assessment, but we consider this approach was not safe during our assessment.

On ward 32 there were additional spaces in corridors to help meet the demand on capacity. We saw and were told that no additional equipment was available to support the care of these patients, the ward did not have additional privacy screens for each patient, patient tables or call bells. The staff had purchased doorbells to use as patient alarms. Also, we were told that additional chairs to be used for patients to sit in corridors or additional bed spaces whilst waiting for an allocated bed had pressure relieving cushions, but patients were sitting in the chairs for long periods of time.

There was only 1 shower facility available for patients on the acute medical unit, in the ward corridor. This was functional and clean but there were no showers inside patient bays. It would have been difficult to assist patients who required help with personal care in this shower. This did not provide for the equipment needs of patients with disabilities in line with requirement of the Equality Act 2010.

We found on the frailty assessment unit there were several areas that should have been secured to keep equipment safe and not accessible to patients and the public to keep them safe. For example, areas containing Intravenous fluids, needles, scissors and razors. Although the sluice room, which was unlocked, contained a lockable cupboard for these items, it was also unlocked and contained substances that were subject to Control of Substances Hazardous to Health Regulations which should be stored securely due to the risk of harm to patients.

On ward 32 and in the discharge lounge, portable oxygen cylinders were not stored in a locked room or secured in a cage or against a wall. Health and safety best practice guidance is that oxygen cylinders should be stored securely in a well-ventilated storage area or compound when not in use.

Environmental risk assessments were reviewed annually or more frequently if there were any changes. Each risk assessment included findings, risk score, and actions where required. There was also guidance for staff on completing these risk assessments. We were told by senior leaders that there were several actions being implemented as part of the Clinical Estates Strategy delivery plan.

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, and development.

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While the service planned and managed staffing in line with national guidance where applicable and considered the use of bank staff when staffing levels fell below these requirements, staff told us there were not always enough qualified, skilled and experienced staff available when required. However, the trust had seen both numbers of doctors and registered nurses increase by just over 4% over the past 12 months.

The trust committed to a minimum nurse staffing ratio of 1 registered nurse to 8 patients on days, and a minimum of 2 registered nurses per inpatient area at night. If there were more than 24 beds or where patient acuity was deemed high, this was increased to 3 registered nurses at night. Care hours per patient day is a measure of workforce deployment that can be used at ward level. It takes account of the acuity and dependency of patients on the ward. There is a national requirement that 80% fill rate must be met.

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From information we received we found that between February 2024 and January 2025 there were several wards that did not meet 80% of nursing staff required to care for patients. Between July 2024 and January 2025 there was a total of 80 times that wards did not have the correct number of registered nursing staff available during the day and 46 times at night. For unregistered nursing staff there were 86 times that wards did not have the correct number of staff available in the day and 46 times at night, the most being in December 2024, when the trust was significantly challenged with high rates of sickness absence.

On reviewing incidents reported related to staffing we found that several incidents showed that, due to staffing issues, intentional rounding was not always completed when it should have been, and pain relief not being given on time. This meant that regular checks had not been done to address patient issues, such as positioning, pain and personal needs.

Following the assessment, we were told in February 2025 the trust had the annual Safer Nursing Staffing and Nursing Workforce Audit meeting (workforce safeguards). This audit established that the trust met 95% of the requirements. Outstanding was an action linked with the Safer Staffing Policy which was still to be presented through the trust governance structures.

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Some resident doctor shifts were vacant due to sickness, vacancy or other reasons between October and December 2024. In total 70% of vacant shifts were filled. There were on average 58 resident medical staff per day rostered to work on a weekday and 18 per day on a weekend in medical services.

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On reviewing the medical rotas provided, day shifts were mostly covered. However, there were several evenings and nights frequently short of the planned medical staffing levels. The trust reported that having 2 ST4 doctors was ideal but we saw that this was not achieved on a number of occasions. NHS doctor grades ST3 to ST6 denote doctors taking part in specialty training, with the numeric value increasing for every year of the program successfully completed as per guidelines for their specialism.

There was a shortage of acute physicians and the service relied on locum cover. However, there was a new consultant due to commence working in the service shortly after out assessment. We were told other acute consultant vacancies for the service were regularly advertised. The service was also looking at job plans to help fill gaps in rotas as well as utilising other trained consultants to help fill the gaps whilst recruitment was ongoing.

The service had in place a `safe care' tool with a red flag system that was used to identify areas in most need of nurse staffing on a daily basis.

There was a system in place for staff to identify and escalate any nurse staffing risks. On reviewing information provided by the service the highest number of raised risks were a shortfall in registered nursing and healthcare support workers. We were told this was due to short term sickness, an increase in acuity and enhanced supervision required. Action had been identified including re-education of matrons and ward leaders in mitigation and resolve as well as the format of safer staffing meetings with the aim of aligning these with benchmarked organisations.

Senior staff told us one of the biggest challenges was staffing and the numbers of staff in substantive posts. The service was reliant on a high proportion of bank and locum staff to support the workforce. The trust is aware of the impact this could have on services and had commenced a weekly task and finish group with this specific focus. Senior staff acknowledged vacancy rate, job planning, skill mix and sickness rate for medical staff as issues they were aware of as high priority for improvement and these were on the risk register.

We observed on several wards that nurse staffing was being managed shift to shift. Staff we spoke with said that this was causing stress, and they did not always receive timely responses when escalating staffing shortfalls.

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Senior leaders told us that consideration was given to the skills, knowledge and experience of staff who were moved to ensure safe care. There were dedicated senior nurses who report into a four times a day operational meeting around the risk and mitigation plans.

There was a daily all site nurse staffing meeting chaired by the head of nursing or associate chief nurse, to ensure safety across the site. A separate meeting was held in the afternoon to review the `late shift' staffing. Nursing leaders used clinical educators to support staff where the staff skill mix was not appropriate.

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A nurse staffing and allied health professional support hub was set up in January 2025 with the aim of facilitating the deployment of staff to clinical areas to support clinical activity and staff wellbeing. At the time of the assessment this was a recent change which meant we were unable to fully assess the impact.

During the assessment we had concerns around staffing in escalation areas particularly the newly opened ward 12 that was an escalation ward. Staff told us there was not always appropriate nurse staff levels and skill mix, especially leadership skills available. This was to make sure staff were supported to ensure people received consistently safe, good quality care that met their needs. Staff told us that they also felt the daily movement of substantive staff to support ward 12 was having a negative impact on staff morale. Immediately following the assessment, senior leaders told us that on ward 12 the nursing model had been changed to provide adequate staffing for the number of beds as well as an experienced nurse in charge and deputy ward manager.

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On the escalation ward all patients were reviewed by a consultant daily, and there was a resident doctor based on the escalation ward during the day. At night there was a medical oncall team to review patients if required. During our assessment this ward was open as a temporary ward to support capacity, however, senior leaders told us that the ward was decommissioned shortly after the assessment but we had concerns during the assessment when the ward was open.

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Senior staff told us an establishment review for allied health professional (AHP) roles was carried out in 2024. This used national guidance for clinical pathways and highlighted the hospital was understaffed. Staff told us it was a challenge to manage the AHP workload and that some patients were discharged prior to their input or discharges were delayed because of staffing capacity.

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Patients told us staff were busy and in some areas patients felt there was not enough staff. Overall, they told us this had not impacted them being supported to meet their needs but had in some cases caused delays in information being provided about their care and treatment.

The trust was supporting clinical directors to develop clear strategic direction for specialities to support recruitment of staff at all levels.

Staff received core training and required learning on a rolling programme in areas such as infection control, medicines management, manual handling and fire. At the time of our assessment most areas were meeting the trust target of 87%, However there were lower rates of compliance for some subjects, such as Mental Capacity Act at 64%, adult life support at 73%, conflict resolution at 74% and ReSPECT at 73%.

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On reviewing the training compliance rates for medical staff working on the medical wards, most subjects were still not meeting the trust target ranging from 47% to 81%. Only 1 subject was above the trust target which was adult life support 4 yearly which only 6 medical staff were required to complete. Most medical staff had to complete adult life support annually and the compliance rate was 63%. Mental Capacity Act, higher level which included DoLs training for medical staff showed a compliance rate of 47%.

Staff told us they received an annual appraisal. According to trust figures 93% of staff in medical care services had received their annual appraisal. The trust target was 95%.

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There was training available for staff in caring for people living with dementia. At the time of the assessment 229 staff across medical services had undertaken this training and 58 medical staff had undertaken the training. However, as the training was not specifically listed as required the service was not able to identify who must complete the training.

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The staff we spoke with could not clearly explain the training they had received in mental health. Senior leaders told us that staff completed mental health awareness training. New healthcare assistants completed the care certificate which includes dementia awareness training. The psychiatric liaison team had also delivered some training to staff which included training on the Mental Health Act. Senior leaders had identified the need to improve mental health training to manage risks. They were putting actions in place to address this. This was important to ensure that people received the support and care they needed.

There was a clinical supervision process in place for staff and we saw evidence of the process for allied health professionals. Clinical supervision establishes a formal process of support, reflection, learning and development that is of benefit to both newly registered and experienced health professionals by supporting their individual development.

The service did not always assess or manage the risk of infection. Patients were not always being protected as much as possible from the risk of infection.

During the assessment there were a number of areas closed due to infections and a number of cases of respiratory infections, for example respiratory syncytial virus (RSV) and influenza.

Standards of cleanliness and hygiene were not always maintained. Monthly infection, prevention and control (IPC) audits were undertaken across all wards which looked at standards such as cleaning schedules, cleanliness of commodes and hand hygiene. We looked at the results of these audits which showed that commodes were not always found to be clean, for example on Ward 37 between January 2024 and January 2025 there were only 13 out of 23 occasions when the ward was compliant and on Ward 36 there were only 23 out of 36 occasions when the ward was compliant.

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Hand hygiene audits were undertaken by staff being observed. These were at least monthly throughout the year. We reviewed data for medical wards which showed that compliance with standards were not always being met. Overall, across the medical wards at the hospital out of 227 audits that were completed for hand hygiene there was only 9 occasions when staff were fully compliant and 102 occasions when fully complaint with use of gloves when required. However, we observed staff complied with `bare arms below the elbows' policy, in accordance with national institute for health and care excellence (NICE) guidance.

Staff did not always follow infection prevention and control IPC guidance. We observed a member of staff enter a bay on Ward 22 (AMU) without wearing any protective equipment including gloves and leaving the door to the bay open. There was clear signage outside the room due to infection, so that staff were aware of the increased precautions they must take when entering and leaving the room. On reviewing the IPC audits for the ward, we found that between January 2024 and January 2025 there were no occasions when hand hygiene standards were being met and compliance with the use of gloves when required was not met on 11 out of 19 occasions when it was audited. Following the assessment senior leaders told us that the infection, prevention and control team had visited Ward 22 and reiterated to staff that isolation room doors needed to be closed or a risk assessment completed.

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Patients in healthcare settings are at risk of getting infections while receiving treatment for other conditions. Hand hygiene can prevent the spread of germs, including those that are resistant to antibiotics, and protect healthcare staff and patients.

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The service also audited Clostridioides Difficile Infections (CDI) which was undertaken weekly by the IPC team when a patient with CDI was located on the ward. There was a confirmed CDI outbreak on Ward 36 in November 2024. The service was aware of the IPC issues on ward 36 and had put in place additional support and actions.

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When there are periods of increased incidence of infection or poor compliance with standards, we were told that the IPC team completed additional audits. We saw that compliance with IPC standards were discussed at the IPC strategic assurance group and recommendations made, for example improvement plans for wards and sharing of good practice.

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There were a sufficient number of hand wash sinks and hand gels. Hand towel and soap dispensers were adequately stocked. Personal protective equipment and hand sanitiser was available at the entrance to all bays and side rooms. The wards we visited were visibly clean and free from odour.

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There was a cleaning policy in place which outlined guidance for example, in hand hygiene, the use of personal protective equipment and the cleaning of equipment.

There was training available for staff on infection, prevention and control. At the time of the assessment compliance rates for level 1 was 100% and for level 2 the compliance rate was 80%. However, for medical staff working on the medical wards this was 61% for level 2. Aseptic non-touch technique (ANTT) is a specific type of aseptic technique with a unique theoretical and practice framework that combines the aseptic technique, and non-touch techniques. However, compliance rates for medical staff working on medical care wards was 38% for ANTT practical and 75% for ANTT theory.

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Cleaning schedules were in place and clean audits were also undertaken. These were either monthly or weekly depending on the assessed risks or high-risk areas, for example Ward 31, 22 and 24. The results were reported through the governance structures where ward managers reviewed the results and put in place actions if required. We reviewed these audits and found that whilst several areas were not meeting the 95% or 98% target, the majority of these areas were above 90%.

Patient led assessments of the environment (PLACE) in 2024 showed a standard of between 97% and 100% for cleanliness across the wards inspected and 90% and 100% for condition appearance and maintenance. The trust has recruited and trained new PLACE assessors, for example admiral nurses and volunteers to enable them to undertake more robust assessments. The trust also has a PLACE group which reported directly to the patient experience subcommittee and the quality committee.

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The service made sure that medicines and treatments were safe in most cases and met people’s needs, capacities and preferences.

Although medicines were stored securely on most wards we visited; we did find on some wards that medicines were not in their original packaging for example we saw some loose strips or loose vials in some cupboards. In addition, in the AMU fridge we found several medicines which were for patients who were no longer on the ward and vials of medicines that were reconstituted and had passed their expiry date. Concerns were raised with the trust about storage of medicines on ward 12, which during our assessment was open as a temporary ward to support capacity, and actions were taken immediately to address this.

The pharmacy team provided a seven-day clinical pharmacy service to medical wards, this included medicines reconciliation, supply of medicines and discharge support. The trust prioritised medicines reconciliation for those patients on time critical or high-risk medicines. For the patients records we looked at, the pharmacy support was clearly documented, and actions had been completed to ensure medicines were prescribed safely. Data provided showed that 87% of patients on critical medicines were seen by the pharmacy team within 24 hours of admission. For the remaining patients 53% were seen within 24 hours and 65% were seen within 48 hours. We were told that staff capacity limited the team’s ability to see everyone, and so critical medicines had been prioritised as this was the highest risk group of patients. Medicines reconciliation is the process of accurately listing a person's current medicines.

The antimicrobial stewardship group had a clear strategy with defined actions and success profile. The multi-disciplinary ward rounds and clinical reviews were shown to be supporting improvements in prescribing and reviews of antimicrobials. For medical care 80% of recommendations made by the antimicrobial team were actioned within 24 hours. The group tracked their workflow and provided updates to the care groups as well as developing pathways and training for prescribers to improve knowledge and skills in antimicrobial stewardship.

To help facilitate quicker discharges some wards had access to medicines which were prelabelled with instructions on how to take at home. There was a system in place to monitor and restock these medicines when they were used. Where prescriptions were completed in the pharmacy, discharge medicines data showed that the pharmacy turnaround time was consistently above the key performance indicator of 80% within 2 hours. We spoke with staff in the discharge lounge who told us that pharmacy supported them to access discharges in a timely manner and that they felt this good working relationship significantly helped with patient flow.

For certain medicines and treatment pathways, work had been completed and order sets had been developed to support the safe use of medicines. For example, an order set had been developed in collaboration with mental health practitioners for the use of rapid tranquilisation within the medical and emergency departments. This was regularly reviewed by clinical pharmacy staff however no audit had been undertaken to look at effectiveness and if this had improved patient safety. Physicians may use order sets to ensure they follow the same treatment guidelines for every patient.

Missed dose audits had been completed by the trust in 2024. The audits considered all missed doses, but an additional audit had taken place which looked in detail at missed doses of critical medicines. Actions from these audits had been developed with defined time scales. We looked at how quickly critical medicines could be available to patients. In the six months prior to assessment the pharmacy key performance indicator on supply of critical medicines within 1 hour of request arriving in pharmacy averaged 91%.

The trust had a medicines safety strategy which detailed its strategic priorities and how it intended to reach them. Staff told us how they would report medicines incidents and for issues identified during the assessment incident forms were completed and actions provided to the assessment team. We saw examples of how learning from medicines incidents was shared with staff across the trust. The trust had a process for reviewing patient safety alerts and documenting actions completed.