The Queen Elizabeth 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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

At our last assessment we rated this key question requires improvement. The service was in breach of legal regulation in relation to need for consent and safe care and treatment and medicines management. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

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 2. The evidence showed some shortfalls. The service did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

People and staff said they were encouraged to raise safety concerns, and staff understood how to report incidents through the trust’s electronic system. Staff described incidents they reported, including falls, medicines errors and safeguarding. Some staff felt incident reporting was used punitively rather than to support learning. We found not all reportable incidents were submitted, including falls on the Acute Medical Unit (AMU), limiting opportunities to identify learning and prevent avoidable harm. Incident outcomes were not always shared with relevant managers when reported by non‑nursing staff on wards, reducing oversight of actions taken and feedback to staff members.

Safety incident processes were supported by the Patient Safety Incident Response Policy v2. Learning was shared through safety huddles, team meetings and chat groups. Since October 2024, the Patient Safety Team produced a quarterly newsletter to support consistent communication and shared learning across the trust. Quarterly lunchtime learning sessions were introduced in March 2026 to strengthen learning. The effectiveness of this is yet to be measured.

Debriefs followed incidents causing severe harm or death to identify immediate learning and support staff. Rapid reviews were not always completed within 2 working days to formally understand incidents and identify urgent actions. A rapid review following a confused patient absconding identified gaps in safety processes, including missing risk assessments and lack of Deprivation of Liberty safeguards (DoLS) considerations. Not all contributory factors were addressed, including lack of a mental capacity assessment and poor documentation.

From 1 November 2025 to 30 April 2026, 1,917 incidents were reported in medical care, mainly unwitnessed falls and moisture lesions. Endoscopy reported 19 incidents, mainly relating to biopsy labelling and sharps injuries. Managers took action, but leaders acknowledged actions were not always recorded digitally. Requested action plans demonstrating learning and mitigation were not provided. There were 231 overdue incidents, 7 overdue Patient Safety Incident Investigation (PSII) action plans and 76 Patient Safety Responses (PSR’s). This meant that there was a delay in identifying learning and preventing avoidable harm.

Patients and families told us they felt confident to raise complaints. Emergency Care and Medicine (ECAM) and Endoscopy received 210 formal complaints between April 2025 and March 2026. The Trust aimed to respond within 30 working days, but only 68% met this timeframe. Delayed responses risked increasing patient frustration and reducing confidence in the process. Delays were escalated through weekly complaints meetings and, when required, to senior leaders. Where complainant was not happy with the outcome of the trust’s investigation, they were able to take this to the Parliamentary and Health Service Ombudsman (PHSO). We were told that 3 complaints were escalated to the PHSO in the last 12 months, we were not told if these were upheld.

The service had not reported any never events for medical care or endoscopy service in the last 12 months.

The duty of candour (DOC) is a legal and professional requirement for health and social care providers and professionals to be open and honest with patients (or their families) when things go wrong with their care or treatment, specifically if it causes or has the potential to cause significant harm. In the last 12 months, 30 reported incidents met the threshold for DOC. We requested copies of the last 5 DOC letters but these were not provided.

Staff were required to complete mandatory training which included topics such as basic life support, fire safety and manual handling. We requested mandatory training compliance for nursing and medical staff and found that staff were not compliant in 10 of the 29 topics. Poorest compliance was seen in Basic Life Support (BLS) (59.6%), Learning Disability and autism training (32.9%), and safeguarding adults (54%). Divisional meeting minutes showed that leaders took action to address non-compliance such as rostering all medical staff to complete training and BLS is being provided on ward areas to non-compliant staff.

We requested clinical staff compliance for training on recognising and responding to mental health needs, learning disabilities, autism and dementia. Mental health awareness compliance was 87.6%. Only 36.8% of staff had completed the face‑to‑face Oliver McGowan Mandatory Training. This training was delivered by an external provider, and sessions were reported as full. The learning disability team was exploring alternative options to increase capacity and improve compliance.

NaPSA (National Patient Safety Alerts) and MHRA (Medicines and Healthcare products Regulatory Agency) recalls are urgent official safety notices issued in the UK to protect patients from unsafe or defective medical devices, equipment, and medications. The trust provided evidence that action had been taken to national safety alerts in a timely manner.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Senior leaders informed us safety huddles were held on medical care wards to discuss operational and clinical demands. We reviewed safety huddle documentation and found that these were not recorded at every safety huddle and was not in a standardised format. For example, on Windsor ward they discussed staffing, incidents and concerns. Whereas on West Dereham ward they discussed and documented safety concerns, incidents, deteriorating patients, patients for escalation/resus, complaints, discharges, and patients on enhanced care. This meant that every ward was discussing different information at the huddles held twice a day.

The medical wards held daily ward rounds with the multi-disciplinary teams (MDT) to discuss patient logistics and flow, however these were not structured for every ward or held at specific times. The divisional leaders acknowledged that this impacted on timely decision making and flow which they were looking to address.

Most patients we spoke to told us they knew the reason for their admission. They had been involved in their discharge planning and how their ongoing care would be met.

We reviewed the last performance data for referral to medical specialty review in the emergency department and found that 41% of all patients were seen within 60 minutes in line with the trust wide Internal Professional Standards target. Data showed that 42% of patients were waiting for speciality review within the emergency department for more than 4 hours during the day. Following acceptance by a medical consultant, 68% of patients were waiting for more than 4 hours for admission to a ward, of which 89% were geriatric patients. In the last 6 months there had been 9 incidents reported directly related to speciality review delays, which showed that patient’s care was delayed and suboptimal.

Junior doctors told us each speciality had a different referral process which meant there was no consistency and led to delays in patient reviews and care. Senior divisional leaders told us they did not audit the timeliness of speciality review requests to ensure internal professional standards were being met.

Senior leaders made decisions to outlie patients to non‑medical specialty wards during periods of high demand to maintain flow and organisational performance. Although the Outlying Patients to a Different Specialty v5 policy sets clear requirements to minimise known risks, the service did not consistently follow it. Review of 7 patient records on an outlier ward showed no completed decision‑making tools to evidence a formal risk assessment supporting the transfer, and no documentation of discussions with patients or families explaining the need to outlie, as required by policy.

There had been 9 reported incidents in the last 12 months in relation to outlier patients. These related to a lack of medical reviews for deteriorating patients, lack of medication review for 20 days and 2 patients admitted directly to outlier wards without a medical consultant review. We were not assured that systems were effective to keep outlier patients safe and that senior leaders were following policy to reduce the known risks associated with the practice of outlying.

Medical discharge summaries were issued on discharge to support continuity of care. Completion was not formally audited but monitored monthly against the standard of sending summaries to GPs within 24 hours. Individual performance was shared with the division for action. The target was 100% compliance. Review for the past 6 months showed 32 patients were discharged without a summary, indicating gaps in adherence to expected practice.

Since October 2025, the stroke service had implemented video triaging by stroke trained nurses 7days a week, to improve timely diagnosis and order CT scans prior to arrival.

Medical staff reported frequent delays for patients awaiting investigations such as MRI and CT, which affected timely decision‑making and discharge. We requested data on the number of urgent MRI and CT scans reported within 4 hours for medical care patients. This data demonstrated that urgent CT scans were completed and reported within the 4 hour target with urgent MRI scans was 76%. Timely imaging is critical to avoid delayed diagnosis, treatment and preventing avoidable harm.

There was a lack of 7 day service of therapies and specialty nurses to support specialist input, rehabilitation and discharge to optimise flow of patients within the division.

The World Health Organization (WHO) Surgical Safety Checklist, a tool used in the NHS to improve patient safety during surgical procedures within the endoscopy unit. Audit data for the last 6 months showed good compliance.

The trust used a standardised handover document to provide information when patients were admitted to wards from the emergency department. We saw this being consistently completed and evidenced within patient records.

An electronic system was used to effectively communicate alerts to the right person instantly. For example, we saw evidence of the diabetic specialist nurse being alerted to a patient and they had a review within 1 hour.

Electronic systems supported the identification of patients with known conditions, allergies and needs. For example, the palliative care team received alerts if known patients were admitted which enabled timely reviews. However, the use of paper records and different electronic systems meant that staff were having to use multiple records for one patient.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately.

Safeguarding training compliance was 54.04% for adults and 70.8% for children. We were told bespoke training was being provided by the safeguarding team to provide further opportunities for staff to increase compliance. All staff knew how to make a safeguarding alert, and did when appropriate. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Only 36.8% of staff had completed the face‑to‑face Oliver McGowan Mandatory Training. This training was delivered by an external provider, and sessions were reported as full. The learning disability team was exploring alternative options to increase capacity and improve compliance.

The service did not have effective processes to implement the Mental Capacity Act (MCA) or Deprivation of Liberty Safeguards (DoLS) in care records when caring for those who may lack capacity to consent to make their own decisions, or who are subject to restrictions on their liberty.

The trust’s MCA lead undertook an MCA and DoLS audit in October 2025 across the care of the elderly wards following concerns from social services about the use of restraint and enhanced monitoring without consideration of DoLS. The audit reviewed compliance with the Mental Capacity Act 2005, Deprivation of Liberty Safeguards, Enhanced Observation Policy, and Safe Use of Patient Safety Mittens. It found limited application of the MCA, poor recognition of when patients were being deprived of their liberty, and insufficient documentation relating to care and treatment decisions, including patient refusal, use of constant enhanced care, and continued use of mittens. Recommendations included delivering bite‑size learning and incorporating discussions into ward huddles.

We reviewed 13 records where MCA was indicated due to fluctuating capacity or a diagnosis of dementia. We found only 2 out of 13 records supported all clinical care delivered on wards and in line with policy, including best interest documentation. We were not assured senior leaders were taking appropriate action to ensure staff were delivering care within a legal framework where restraint and restrictions were imposed. The divisional leaders told us there was a plan to audit MCA and DoLS across all wards to monitor improvement and compliance.

The ECAM division did not monitor the duration and number of patients receiving enhanced care in line with policy. Senior leaders relied on the enhanced observation assessment record, but this alone did not demonstrate enhanced care was correctly prescribed or delivered in line with trust policy. The most recent trust‑wide enhanced observation audit (2025–2026) identified ongoing gaps, including ensuring the correct level of enhanced observation was prescribed and that mental capacity assessments were consistently completed when required. Although overall trust compliance had improved compared with the previous year, the audit did not provide division‑level assurance, and stronger performance in other divisions may have masked poorer compliance within ECAM.

Following our onsite assessment, we requested the policy for when a registered mental health nurse is used on medical care ward. This was not provided by the division.

Safeguarding assessments were completed for patients within the patient risk assessment document on admission. We reviewed 9 sets of patient records and found staff screened and referred patients with identified safeguarding concerns. This demonstrated that staff were reporting concerns and resulted in action being taken to support and protect patients.

The trust held a monthly Safeguarding and Mental Health Forum meeting. This meeting was chaired by the Deputy Chief Nurse who was level 5 trained and there was representation from each Division as well as key stakeholders around the Trust to ensure the timely review of all safeguarding referrals.

We requested the last 6 months of safeguarding meeting minutes. We found that there was discussion of quality and performance across all divisions, review of MCA and DoLS completion and sharing of information with the local authority.

We scored the service as 1. The evidence showed significant shortfalls. The service did not work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe and responsive to their needs.

The management of risks to people across their care journey was not effective. We reviewed care records for completion of risk assessments and response to deterioration in line with trust policy to manage risk and safety.

Review of 10 care records showed that 6 patients did not have pressure‑ulcer risks mitigated in line with policy, meaning staff were not always taking timely or adequate action to prevent avoidable harm. We requested 3 months of audit data for all medical wards. Audit data showed that there were inconsistencies with the completion of risk assessment within 6 hours of admission, variable completion of daily foot care, and limited evidence of discussions with patients about pressure‑ulcer risk. We were not assured that senior leaders were effectively monitoring or addressing pressure‑ulcer risks to reduce avoidable harm.

We reviewed 10 patient care records for completion of falls risk assessment and mitigation to identified risk. We found that 4 patients did not have fall risk measures in place to mitigate the identified risk. Therefore, we were not assured that staff were mitigating identified risk of harm in line with policy. We requested falls audit data for the last 3 months on medical care wards. We were provided with a summary of falls activity from February to April 2026. There had been a total of 31 inpatient falls. Learning had been identified and focus education such as the introduction of yellow signage of lying and standing blood pressure procedure. We were told that audits had been introduced across those areas, supported by monthly ward-based tendable audits to ensure falls prevention strategies were followed and monitored by each division.

We reviewed 5 care records where a Malnutrition Universal Screening Tool (MUST) score of 1 indicated a medium risk of malnutrition on admission. We found 4 patient’s records did not have fully completed food charts to demonstrate adequate nutrition and hydration was being met. Incomplete documentation of nutritional intake leads to missed interventions, resulting in poorer patient outcomes and increased mortality risk.

Staff did not consistently recognise or escalate deteriorating patients in line with trust policy. Although deterioration was identified using the national early warning score 2 (NEWS2), review of 4 care records did not have documentation to support an assessment or decision-making regarding frequency of repeat observations in response to the NEWS2 score. When we requested NEWS2 audit data for medical wards, senior leaders confirmed that the division did not monitor NEWS2 completion or escalation, limiting oversight of whether deteriorating patients were being identified and escalated appropriately and in line with policy.

Ward staff could escalate deteriorating patients to the critical care outreach team who were available to attend and respond 24 hours a day, 7 days a week. Processes of escalation of such patients was supported through the Prevention and Management of the Deteriorating Adult Patient and Critical Care Outreach Team Operational Policy v7.

Audit data provided by the trust’s deteriorating patient lead (January–December 2025) showed only 32% of patients had repeat observations completed within 30 minutes and 32% were reviewed by a medical registrar or above. No action plan accompanied the findings. Divisional leaders told us they intended to revise their internal audit tool to generate more meaningful data aligned to national and local standards, enabling better assessment of how deteriorating patients were identified and managed on medical wards.

Staff we spoke to told us they did not feel they had the skills or training to safely manage patients with mental health needs and challenging behaviour and it impacted their wellbeing. A review of patient safe incidents showed that were 29 open incidents relating to confused patients absconding and aggressive behaviour. We saw evidence that a patient absconded from a ward twice with a lack of documentation that the behaviour was escalated, there was no increase in special observation level and a missing persons form had not been completed. We were not assured that staff were adequately trained or able to manage challenging behaviours.

Martha’s Rule is an NHS patient safety initiative that gives hospital inpatients, their families, and carers the legal right to request an urgent, independent review if they are worried about the patient's rapidly deteriorating condition and feel their concerns are not being addressed. The hospital had posters displayed in all ward areas to empower patients, families and staff to escalate any concerns.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

All ward areas were accessible through swipe access or intercom to ensure safety and security. However, we did observe a lack of professional curiosity when holding doors open to people entering ward areas. Care of the elderly wards were dementia friendly with day rooms and a garden area to enable people to have a sense of normality during their admission.

At our previous assessment in January 2022, we found that resuscitation equipment was not checked and maintained in line with policy. During our onsite inspection on 28 and 29 April 2026, we saw evidence that staff completed safety checks of specialist and emergency equipment in line with policy.

Staff understood how to order specialist equipment such as pressure‑relieving cushions and mattresses, and there were clear processes for reporting and servicing faulty equipment. Staff knew how to log faults, and next‑due‑date stickers were visible on electrical items reviewed during the assessment. However, post‑visit data showed 4–5 pieces of equipment, including thermometers and vital‑signs monitors, were overdue for testing on most medical wards, indicating gaps in equipment safety oversight.

We observed that call bells were accessible to patients if they needed support. However, people told us that often there was a delay in staff responding to call bells due to poor staffing levels.

Senior leaders occasionally made decisions to reverse‑board patients to day rooms during periods of high demand to maintain patient flow. Nursing staff told us they used their clinical judgement to ensure only suitable patients were moved to these areas. Often these were those going home that day. A discharge lounge was available for patients awaiting transport, medications, or confirmation of restarted care packages. However, this was only suitable for patients that were not bed bound, limiting its usage.

The trust’s fire safety officer was supporting the completion on fire drills on wards to ensure that staff were responsive in line with the Fire safety policy v15. The completion of fire drills were monitored and improvements were being made within fire safety following a fire service safety inspection in April 2026. During our onsite assessment, there was a fire on a medical ward. We observed staff and leaders evacuate patients and people from the ward area rapidly.

The endoscopy unit was Joint Advisory Group (JAG) on gastrointestinal endoscopy accredited. This accreditation means that the service consistently met specific standards in providing highly secure, clean and patient-focused environments for patients.

There was a lack of tier 4 mental health beds for patients which was having significant impacts on capacity and flow as well as staff. Senior leaders within the trust were planning on carrying out a review to evidence the reasons for the high acuity and demand to present to the local authority. This is a suboptimal environment for patients in crisis, leading to a poor patient and staff experience, with delayed access to the required specialist assessment and treatment.

During the assessment we found 2 medicines cupboards not locked on a ward. This was escalated immediately and the nurse in charged locked them.

During the onsite visit, we found cleaning chemicals stored in a lockable room, however some chemical such as chlorine tablets were left out and not within a lockable cupboard in line with Control of Substances Hazardous to Health (COSHH) regulations. Staff immediately locked this away once highlighted. We found that ward staff were not always aware of how to store COSHH substances safely to keep patients safe.

Staff disposed of clinical waste safely. Sharps bins were labelled correctly and not over-filled. Staff separated clinical waste and used the correct bins.

We scored the service as 1. The evidence showed significant shortfalls. The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

The trust used an electronic system to determine the required number and grade of staff based on patient acuity. A supernumerary nurse reviewed this daily and moved staff across the division to maintain minimum safe staffing levels. Staff told us that frequent movement negatively affected morale. Managers logged staff moves to avoid repeatedly reallocating the same individuals, although they acknowledged this was sometimes unavoidable due to skill‑mix requirements on specific wards.

Nursing rosters showed staffing levels on the short‑stay ward and acute medical unit were below 85% over the past three months. The trust reported 61 incidents in the last six months where unsafe staffing affected the ability to manage patient acuity and dependency. Reported impacts included delayed blood‑glucose monitoring, call bells not being answered promptly, and incomplete care rounds. Patients we spoke with told us they often waited for assistance and felt nursing staff were under significant pressure.

Staff told us when they escalated inadequate skill mix, additional support was not always provided. Ward teams were sometimes advised to seek help from neighbouring wards, but this was often inappropriate due to those wards facing their own operational pressures. Staff feedback and incident reports showed that patients requiring enhanced observations further reduced the availability of staff to meet wider care needs when staffing levels were below planned. This directly affected staff wellbeing, with staff reporting missed breaks and feeling helpless and stressed.

Completed competency documents were kept in individual staff files and portfolios, meaning leaders could not easily demonstrate how many staff on each ward had completed the required competencies. Ward managers and nurses in charge could view competency status on the duty roster, but this did not provide organisational oversight. We were told work was underway to ensure completed competency forms would be held centrally by the education faculty.

Staff told us there was no permanent resident doctor or consultant covering outlier patients, which affected timely continuity of care. They reported that consultant decision‑making often occurred late in the afternoon, delaying same‑day discharge, slowing medical management decisions, and negatively impacting patient flow and overall efficiency.

Following our assessment, divisional leaders told us they had introduced a weekly rota for consultant and junior‑doctor cover to improve continuity and safety for outlier patients. However, review of the planned versus actual outlier rota (February–May 2026) showed 6 days with no resident doctor reviewing outlier patients, indicating ongoing gaps in medical oversight. We were not assured that there was sufficient staffing to cover medical outlier patients.

Mandatory training compliance for nursing and medical staff overall was 85.8%. They did not meet compliance in 11 out of 32 mandatory topics. It was significantly poor in learning difficulties (32.9%), basic life support (59.6%), and safeguarding adults (54%). We were not assured that staff were completing mandatory training in line with policy to ensure they had the necessary skills and knowledge whilst providing care and treatment.

Some staff told us low staffing was a regular occurrence and was having a direct impact on morale and they could not always meet the demands placed on them in a timely manner. The trust did not use agency staff but tried to fill gaps in rosters with bank shifts. This meant that staff were familiar with the trust processes and wards.

Appraisal rates for nursing staff were 84.6% against a trust target of 90%.

Medical staff told us there was no formal induction checklist when rotating into the division. When we requested evidence of completed local inductions for medical and nursing staff over the past six months, divisional leaders told us this information was not held centrally, and local induction processes were not consistently completed across all ward areas. An induction working group had been established following our visit to develop a new Induction Policy. A structured local induction is essential for patient safety, staff wellbeing and operational efficiency.

Nursing vacancy and sickness rates were 8% and 5.72% against the trust target of 10% and 4.5% respectively. Whereas medical staff were higher for vacancy (15.1%) and sickness (5.9%)

There were specialist therapists and on call consultants were available for all specialist areas to support out of hours medical staff. However, there were not enough staff to meet the demand of the patients. For example, there was insufficient stroke therapists to provide rehabilitation in line with the national guidance. Inadequate speciality medical staffing was cited within the divisional risk register.

Specialist nurse services were not staffed adequately to support the demand of patients within the division. For example, the diabetic specialist nurses staffing was not in line with national guidance which meant that patients admitted on a Friday were not reviewed until Monday resulting in increased length of stay and delays.

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.

Staff maintained equipment well and kept it clean. We were told by ward managers that equipment was cleaned following use for every patient, however ‘clean’ stickers were not visible across all ward areas to indicate it had been cleaned. We saw staff clean equipment after use, such as a commode.

All ward areas were visibly clean, had required furnishings and were well-maintained. Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. We observed staff washing hands after patient contact and wearing personal protective equipment (PPE), such as gloves and aprons where indicated in line with national guidance and trust policy.

The trust infection prevention and control lead was visible and known to staff on the medical care wards. During our onsite assessment we saw that there had been an outbreak of norovirus. We observed the IPC lead reminding staff of the signs and symptoms and importance of good IPC practice to reduce further spread at the morning huddle.

Wards carried out IPC audits and review if data for the last 3 months showed all wards were complaint. Patients were screened for healthcare associated infections such as Methicillin-resistant Staphylococcus aureus (MRSA) within the emergency department unless patients were admitted directly into the medical assessment unit where screening was carried out. Patients admitted from outside of the Norfolk and Waveney University Hospitals Group were swabbed for Carbapenemase-Producing Enterobacterales (CPE) and placed in a side room whilst awaiting results.

IPC performance was discussed at monthly senior nursing forum meetings. Meeting minutes reviewed showed that action was taken to support ward areas where there were outbreaks. For example, in April 2026 Stanhoe Ward had been declared as supportive measures following 2 Clostridioides difficile cases.

The endoscopy unit practiced strict decontamination pathways to ensure meticulous decontamination, tracking and storage according to national guidelines. Units had clear separation between clean and dirty areas and a one-way system to prevent cross contamination and infection.

We saw evidence of testing water outlets for preventing healthcare-associated infections in vulnerable patients by identifying and controlling harmful microorganisms like Legionella and Pseudomonas aeruginosa. Action was taken in response to a positive result for legionella on a medical care ward and subsequent test results were negative.

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.

A clinical pharmacy service supported the Acute Medical Unit (AMU) five days a week. However, not all wards received a daily pharmacy service, and input varied across areas and at weekends. There was a clear process for staff to access medicines advice outside these hours. Pharmacy teams worked closely with clinical staff in some areas, particularly in AMU, where they reviewed discharge prescriptions and supplied medicines promptly to support patient flow.

Staff understood the importance of time-critical medicines, such as insulin and anticoagulants, and used prompts and communication systems to prioritise care. For example, in the discharge lounge, staff identified patients who required medicines and took action to reduce delays. Both pharmacy staff and nursing staff provided medicines counselling where possible and supported patients to manage their own medicines where appropriate.

However, pharmacy input was not consistent. The discharge lounge did not have dedicated pharmacy support, and delays in medicines supply occurred during instances when pharmacy cover was limited. Medicines reconciliation was also not completed consistently, and trust targets for completion within 24 and 72 hours were not met over the previous six months. Staff did not always record medicines counselling, which reduced assurance that patients received appropriate advice.

Staff did not always record weights on the patients’ records, or the use of prescribed drink and food thickeners and often relied on verbal communication. However, the service had started a quality improvement project to improve weight recording.

Services had in place processes to manage patients transferred from areas where they use paper records to electronic records.

The service generally managed controlled drugs safely, with regular checks, accurate records and pharmacy oversight. However, audits identified ongoing risks linked to record keeping. Some areas did not maintain up-to-date indexes or complete records accurately, and some wards continued to hold expired controlled drugs.

During our previous assessment in January 2022, we found medicines were not stored securely and issued a requirement notice. During the assessment carried out 28 and 29 April 2026, we identified the same issues. Medicines storage and the clinical environment did not always support safe practice. Some clinic rooms did not meet infection prevention standards, and we found expired medicines in some areas. Access to medicines storage was not consistently restricted to authorised staff, increasing the risk of unauthorised access.

There were also gaps in medicines safety guidance. Staff did not always have clear instructions for administering medicines via feeding tubes, and awareness of national safety alerts, including for valproate and food thickeners, was limited.