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

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

At our last assessment we rated this key question as Good. At this assessment the rating had changed to requires improvement.

This meant that some aspects of the service were not always safe and there was limited assurance around safety.

At this assessment we found breaches relating to safe care and treatment and dignity and respect.

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. Although the service did investigate and report safety events, lessons were not always learnt to continually identify and embed good practice.

Staff knew how to report incidents and gave examples of the type of incidents they had reported. Incidents were investigated by managers, and staff would receive support and feedback by email. However, staff in children’s urgent and emergency care (UEC) told us support for staff following and incident was often variable. Medical staff often needed to be reminded that a debrief/support was required by the paediatric nurses.

We requested data relating to incidents involving deteriorating patients within the UEC department From May 2025 to April 2026, 61 incidents were recorded. The data showed fluctuations in the number of incidents reported. This indicated that sufficient lessons were not being learnt, improvements were not being embedded to mitigate the risk of patient deterioration within the department.

We observed learning from incidents being discussed at morning staff huddles. It was also shared by department newsletters, lunchtime learning sessions, bitesize learning and a quarterly trust wide newsletter to enable cross department learning. We saw some evidence that learning from incidents had influenced policy changes and staff training.

Between 1 November 2025 and 30 April 2026, 1709 incidents were reported in the Urgent and Emergency Care (UEC) department. Patient safety incidents were reported using the Patient Safety Incident Response Framework (PSIRF) and reviewed by the lead nurse for risk and governance. These reports were discussed at the Divisional Team bi-weekly PSIRF meeting. Rapid reviews and round table discussion were undertaken of patient safety incidents. They were also shared at the Emergency Care and Medicines (ECAM) divisional meetings, clinical governance meetings and staff meetings. This allowed any immediate actions to be implemented, share learning and drive improvements.

Staff understood the importance of being open and transparent when things went wrong and understood Duty of Candour. Duty of Candour is the legal and professional responsibility of healthcare providers to be open and honest with patients and their families/carers when something goes wrong with their care, that has caused or could have caused harm or distress. There were 13 incidents within the department that met the criteria for duty of candour to be triggered in the 12 months prior to our assessment. One of these incidents resulted in policy changes and further staff training. Information about duty of candour processes to follow were displayed within the department for patients to see.

There was a trust wide complaints policy that was in date and version controlled. Staff knew how to direct patients to make a complaint if needed. They told us if a patient complained verbally they would refer them to the nurse in charge, if not they would direct them to the Patient Advice and Liaison Service (PALS).

How to complain and provide feedback information was displayed within the department and waiting areas. Friends and family test information for feedback was also displayed in various different languages. Feedback cards were also available for patients, their families and carers to complete.

There were 55 complaints relating to UEC, 53 in relation to adults and 2 relating to children within 6 months prior to assessment. Main themes were communication, delayed care and discharge concerns. ECAM as a division had a total of 222 complaints and were 68% compliant in responding to them within 30 days as per policy. Compliance data was not department specific we were not assured complaints relating to UEC had been responded to within policy time frames.

Although UEC had governance structures and policies supporting learning from incidents and complaints, evidence reviewed showed repeated incidents involving deteriorating patients and complaints. Systems used to identify patient safety risk and implement improvements were not always effective and were inconsistent.

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.

Patients could either self-present to the department or be brought in by ambulance. At the main public entrance, between the hours of 9 am - 9pm, patients could be seen at a streaming desk by a primary care streaming nurse, who triaged and signposted them for further assessment. The services streaming area became very busy, patients queued outside the department and the area around the streaming nurse and receptionist became crowded. The triage nurse did not have oversight of people that were queuing outside and we were not assured staff had safe oversight of patients whilst waiting to be seen.

The patients’ conversations with the triage nurse could be overheard and the area lacked privacy and dignity. Private and confidential information given to the receptionist whilst booking in could also be heard raising concerns around General Data Protection Regulation (GDPR) and information governance.

We raised concerns regarding the current streaming process, the lack of clinical oversight of patients waiting and lack of dignity and privacy to senior leaders. Leaders told us the service was undertaking a phased refurbishment of the department. The services current streaming model had been implemented in 2025 with improvement work due to start in July 2026. Completion date for this work was not shared; we were not assured timely actions were being taken to mitigate risks to patients. We issued a warning notice to the Trust for failing to meet the regulations relating to safe care and treatment and dignity and privacy.

Staff used recommended national triage tools and guidance for emergency care. This was supported through staff training and guidance. National NHS benchmarking triage targets stated 85% of all patients coming into the department should be triaged within 15 minutes of arrival. Between April 2025 and March 2026 audit data showed the service ranged between 61% and 73%. This is was a previous breach in regulation whereby CQC took enforcement action against the Trust.

The department used a system of coloured chairs to indicate a patient’s stage of triage. Red chairs where for the second more detailed triage, patients were called into an assessment room that was more private where initial clinical observations were taken. They would then be moved to blue chairs to receive further observations and primary tests, for example blood tests. Triage, streaming and waiting room staff were trained to recognise and escalate any patient presenting with a life-threatening conditions. Staff told us any patient deterioration would be escalated to the Nurse in Charge (NIC) and would ensure patients were seen in the appropriate area in the department promptly.

The service had a Same Day Emergency Care (S:DEC) and Frailty Same Day Emergency Care (FS:DEC) units.
S:DEC was open between the hours of 8.30am and 00.30 am. It was used for adults presenting with acute medical conditions to be seen on the same day and discharged home. There was an inclusion and acceptance criteria and could accept referrals from UEC, NHS 111, General Practitioners (GPs) and directly from the ambulance services. Leaders told us the unit reduced admission and improve patient flow within UEC.

However, this department was not always being used appropriately. Outside of opening hours S:DEC was regularly used as a discharge holding area and for medical overnight stays for patients awaiting discharge from ward beds. This had an impact on the capacity for S:DEC to accept referrals the next day. Staff told us S:DEC was usually full by midday, if it had been used overnight and impacted on patients flow within UEC.

The FS:DEC area was used to identify and assess frail patients, over the age of 75. This enabled teams to initiate treatment pathways to avoid readmission and promote safe and rapid discharge. The frailty team assessed and accepted referrals from UEC and external system partners for patients who met the inclusion criteria. This provided specific tailored pathways for frail patients, and the frailty team would arrange supported discharges with community teams. However, staff told us that transport arrangements often caused delays in discharging patients which further impacted flow within departments.

Staff within FS:DEC had welcomed a trial to deliver a 7-day service over the winter, however due to financial restraints it had reverted to a Monday to Friday provision.

During our assessment we observed the service’s patient flow and staffing meeting that was held every 2 hours. This was led by the flow coordinator and was attended by the nurse in charge (NIC), the department Matron, the Emergency Physician in Charge (EPIC) and the service manager.

Children and young people attending the department would be streamed and booked in following the same process as adults. Following this they were directed into the children’s ED which was accessed by a swipe card. Once in Children’s ED they would be triaged by nursing staff. Those with known long-term medical conditions, who had a hospital passport, could be directly referred to the appropriate wards. We requested data regarding children’s ED waiting times, we did not receive a breakdown of this data so we were not assured children were being seen in line with the services and national guidance.

Patients could experience long length of stays in the department. During assessment the longest wait was recorded as 13 hours. Data for March 2026 showed 78% of patients that did not require admission where seen and decisions around care made within 4 hours. Patients requiring admission had extended length of stay following the 4 hour decision to admit, this was at 34% against the trust target of 91%. This data demonstrated patients were waiting longer in the department to be admitted to inpatient wards, indicating a flow issue across the wider trust and wards.
Staff told us there were delays in specialist reviews and patients were not seen by specialist teams within an hour of referral. There was a lack of escalation process for these delays.

Leaders acknowledged the delays in specialist reviews within UEC was on the services risk register. Between October 2025 and March 2026, 16,724 attended ED department. Of those 6386 patients remained in ED for longer than 12 hours.

Patient emergency escalation pathways were not always consistent. At the time of our assessment staff told us there were no agreed trauma activation criteria or pathway and staff told us the EPIC would decide on a case-by-case basis. This was not in line with national guidance. Following our assessment the service launched a trauma team activation criteria and guidance for staff.

During our 2-day assessment ambulance offloads to clear were on average 16 minutes, with the longest handover to clear taking 32 minutes for a complex patient. Ambulance staff and the Hospital Ambulance Liaison Officer (HALO) told us this was unusual and often there were long delays with ambulance staff often having to take patients back to the ambulance due to lack of capacity within the department.

Data received indicated that between October 2025 and March 2026 10,728 patients arrived by ambulance. Out of these patients 1151 patients were handed over within 45 minutes. Handovers within 45 minutes is an NHS England (NHSE) protocol that states that transfers from an ambulance into an ED must be completed within 45 minutes of arrival. Delays in ambulance handovers was on the department risk register. Delays in offloading patients from ambulances increased the risk of clinical deterioration, delayed treatments and diagnosis.

We requested copies of the services discharge guidance for staff to follow. The service did not currently have a standardised discharge process. We were not assured staff had the most up to date information and guidance to support patients when discharging from the department.

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.

The Trust had a safeguarding lead for both adults and children trained to level 4, the trust Chief Nurse was trained to level 5. Staff had access to the trusts safeguarding policy that was in date and version controlled. There was not a safeguarding lead for adults within the department but there was a safeguarding champion. Nursing staff were aware of the safeguarding champion for the department and the lead for the hospital, however not all medical staff were aware of who they were or where to find them.

The trusts safeguarding team were available Monday to Friday between 9am -5pm. Outside of these hours The department would be supported by safeguarding practitioners within the hospital. Safeguarding was discussed at daily safety huddles, Safeguarding and Mental Health Forum meetings, staff meetings and clinical governance meetings. Safeguarding was also shared with staff in patient safety newsletters.

We reviewed 8 patients care records. Mental capacity assessments were completed and recorded in the patient care records, the necessary safeguarding assessments were completed and referrals made.

A representative from the safeguarding team visited the department daily and monitored the electronic patient record system to identify any possible safeguarding concerns. Reception staff had access to the Child Protection Information Service (CP-IS) which allowed staff to check children under the age of 18 and women of childbearing age who attended the department for safeguarding concerns. Any concerns would be recorded in the electronic system to alert nursing and medical staff.

Children’s UEC had a child safeguarding lead. Staff told us that they had a very good relationship with the safeguarding team who provided help and guidance when needed. Between November 2025 and April 2026 there were 47 adult and 161 children’s safeguarding referrals made. There were weekly meetings to discuss safeguarding both adults and children.

Training in mental health awareness, the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) showed varied training compliance rates. For example, medical staff were below the trust target at 77% for MCA training. Staff also received the Oliver McGowan training in Learning Disability and Autism. This training incorporates both e-Learning and face to face training. There was poor compliance for the face-to-face element of the training, for example nursing staff were 33% compliant and medical staff were 7%. Leaders told us there had been challenges with the face-to-face training as this was provided by an external party and spaces were limited. The trusts learning disability team where looking for a new provider to improve compliance.

Not all staff were fully compliant with mandatory safeguarding training. Staff we spoke to were aware of safeguarding process and how to raise concerns and make referrals to local authority and the hospital safeguarding team. However, both nursing and medical staff were below the trust target of 80% compliance for safeguarding level 3 for adults and children. Nursing staff had a compliance of 54% for safeguarding adults and 71% in children.

Medical staff had a compliance of 58% for adults and 73% for children. Low training compliance was raised following the inspection in 2022. We were not assured leaders had taken the appropriate action to ensure all staff had received the necessary training for safeguarding to protect adults and children from harm.

Leaders told us they would carry out safeguarding supervision if requested by staff. The services policies outlined the importance of professional safeguarding supervision; however we did not see any evidence this was taking place.

We scored the service 1. The evidence showed significant shortfalls. The service did not work well with people to understand and manage risks. Staff did not provide care to meet people needs that was safe and supportive.
The service did not always monitor patients within the department that were at risk of deterioration. Systems used lacked consistent oversight to ensure staff were reviewing patients National Early Warning Score (NEWS2) to detect and to respond to any clinical deterioration. NEWS2 is a scoring system used across the NHS to identify clinical deterioration on adult patients.

We reviewed 8 patient care records and found inconsistencies in the timing, review and monitoring of NEWS2 scores as set out on the Adult Clinical Observation NEWS2 chart used within the department. Staff told us that NEWS2 scores of 5 or more were verbally escalated by nursing staff to the Emergency Physician in Charge (EPIC) but this escalation was not always documented. Medical staff could not tell us which patients were at high risk of deterioration and could not give us assurance they had oversight of the patients within the department.

The services electronic patient record system (EDIS) could not record Paediatric Early Warning Scores (PEWS), it could only record NEWS2. Children’s observations were therefore entered into the system using a free text. Staff told us that they aim to take observations hourly but if the department becomes busy this is not always possible and observations were often missed. Staff told us they were aware of escalation policies but did not know where to find them. Children’s ED did not always have a consultant assigned to them for any escalations they would call a Paediatric registrar and call through to majors ED for a consultant or the EPIC to attend.

NEWS2 observations were not audited at department level, audits were completed as an overall trust. This meant the trust could not be assured that departments were detecting, monitoring and responding to acute illness in adult patients, therefore was not able to provide assurance that patients within the urgent and emergency department were being monitored for deterioration.

Sepsis screening tools were not used consistently. For example, in the Rapid Assessment Treatment area (RAT) patients arriving by ambulance and triaged were not always screened. This could delay any required treatments and the sepsis pathway management of care being missed. Data received indicated that between August 2024 and January 2026 monthly audits for completion of the Sepsis 6 care bundle ranged between 0% and 45%. We were not assured patients were receiving all six evidence-based treatment interventions within an hour of being identified as being septic.

Staff in S:DEC told us that when the area is used for medical overnight stays for patients awaiting discharge or ward beds, staff do not always get a full handover of the patients. This led to patient medications and timely observations being missed and diabetic patients not having their blood sugars reviewed.

Completion of risk assessments were inconsistent. For example, we reviewed 8 patient care records and found venous thromboembolism (VTE) risk assessment were not always completed despite patients being in the department for prolonged periods of time and at risk of harm. We requested audit data for VTE assessment across the service. UEC did not carry out audits, however S:DEC showed good compliance of 96% in April 2026 and 100% in May. FS:DEC showed a low compliance of VTE assessment of 63% in April 2026 but an improvement to 96% in May. The compliance target was 100%.

Staff where aware of Martha’s Rule and received training during induction. Martha’s rule is an NHS initiative in England that gives hospital patients and their families the right to request an urgent, independent review if a patient’s condition is getting worse or if they feel that their concerns are being ignored. Staff told us they were finding more people were using this initiative to escalate concerns.

The service had policies, guidance and procedures in place to recognise and escalation deteriorating patients, however these were not always effective and embedded. Due to the inconsistencies in monitoring of NEWS2 scores across departments we were not assured deteriorating patients were being escalated to the necessary specialist teams in a timely manner to prevent harm.

We requested data relating to incidents involving deteriorating patients within the Urgent and Emergency Care (UEC) department for the last 12 months, May 2025 - April 2026. Information provided showed 61 incidents. We found the trust in breach of failing to meet the regulation relating to safe care and treatment. Following our assessment, we issued a warning notice that required the trust to make significant improvements to ensure people were safe.

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.

The majors department had been recently refurbished and was spacious, bright and visually clean. Each patient had their own cubicle with monitoring equipment available. However, we observed that some patients did not have a call bell in reach to call for help or assistance and not all cardiac monitoring equipment was visible enough for staff to monitor for any changes.

Majors had 2 cubicles that were designed to support Mental Health (MH) patients. Both had fixed beds, alarm strips and two doors in and out and were ligature free. The cubicles also had non-recorded surveillance cameras. This enabled the patients to be monitored by security staff, if required, in a separate room if their physical presence was having an adverse impact on the patients wellbeing. However, there was not any signage displayed to let patients know that cameras were being used, albeit not recording. If MH patients presented with both physical and MH needs three cubicles that were all in the line of site of nursing staff could be adjusted to be made “ligature light.”

Ambulatory Majors was a smaller area and was observed to be busy and chaotic. There were cubicles and a seating area. Cubicles were split in 2 by way of screens that gave limited privacy, reduced space and conversations could be overheard. Leaders told us that there were plans to improve the layout of the area as part of the phased department refurbishment.

The resuscitation area had been refurbished with 4 cubicles that were fully equipped. However, there was not a central monitoring system within this area which made it difficult for staff to see patient clinical monitoring equipment through the cubicle windows. At time of our assessment, we observed staff having to move a patient to another resus cubical so they could view the monitor and not all patients had call bells within reach.

Children’s ED was locked and accessed by a call button or swipe card. The area was small and cluttered. There were 3 cubicles and a waiting area which was observed to be very busy. One of the cubicles could be used as a Mental Health (MH) cubicle if necessary and, equipment would be removed and the cubicle made “ligature light”. However, the cubicles were not in the line of sight of the nursing staff when they were in the triage area. CCTV was available within the department.

Children had access to toys and were suitable for younger children. We could not see anything available for older children and teenagers. There was equipment to support additional needs and neurodiversity, for example ear defenders and distraction toys. All cupboards within the department were lockable. Leaders told us there were expansion plans for children’s ED as part of the refurbishment of the department.

The trust had a fire safety officer, and the local fire service completed inspections in January and April 2026. Following these inspections recommendations were made to carry out regular physical or tabletop fire drills with staff. It was not clear if these drills had happened, however staff had received fire safety training, and the department had an up-to-date fire risk assessment in place.

We reviewed 24 pieces of equipment across the ED department. We found 11 pieces of equipment to be out of date for servicing and Portable Appliance Testing (PAT). We could not be assured that all equipment was safe and fit for purpose. This demonstrated a breach in the regulation relating to safe care and treatment and following our assessment we issued a warning notice requiring the service to make significant improvements.

Daily equipment checks were not always completed. For example, audited data from February to March 2026, 2 out of 5 resus trolleys were not compliant with checks. At time of assessment, we found 2 bags of fluid to be out of date, this was escalated to staff and removed. At our last assessment in 2022 it was identified that the trust should take action to ensure that staff carried out checks on specialist equipment and recorded this in line with service guidance, this had not been fully actioned

The service had policies and governance processes in place to support a safe environment for patients, however monitoring and system improvements were not consistent.

This demonstrated a breach in the regulation relating to safe care and treatment and following our assessment we issued a warning notice requiring the service to make significant improvements.

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.

On the two days of assessment the department had enough staff to support patient’s needs. However, staff commented that the department was not as busy as it usually was and staffing was often an issue and breaks were often missed. Staff would be redeployed from other areas of the hospital if UEC was short staffed. These staff would be supported by UEC staff during their shift. We observed a senior leadership meeting where the nurse staffing numbers were discussed. The department’s additional nursing numbers was set at 3%, however at 3% the service was struggling to accommodate mandatory training, planned and unplanned staff absences. Leaders had plans to put forward a business case to increase numbers to 27% over baseline nursing establishment, however no clear timeframes of implementation were shared.

We requested and reviewed data relating to staffing levels. The average fill rate for Registered Nurses (RNs) within the department was 83% during the day and 86% at night. The average fill rate for non-registered nurses was 89% during the day and 108% at night. This suggested the department was at times below the trust staffing target. Leaders told us that a business case had been put forward to recruit 20 more RNs but had no clear timeframes for positions to be filled.

There was a trust meeting every morning to discuss staffing and the Emergency Physician in Charge (EPIC) and the Nurse in Charge (NIC) met every two hours to discuss staffing and acuity within the department. The service had a ‘Safe Nursing’ Standard Operating Procedure (SOP) to review staffing levels. The SOP directed staff on the steps and actions required when staffing was insufficient, to keep patients safe. We did not see any evidence to show that times of low staffing were recorded within the services incident system. We were not assured the service monitored occasions when the department was not staff safely.

Medical staffing levels was also a concern and appeared on the department risk register. The service did not always have enough medical staffing to meet the service requirements within the department. Consultant numbers were not aligned with the Royal College of Emergency Medicine (RCEM) recommendations for the size of the department, which also put staff at risk of burnout. Locum staff were used to fill staffing gaps, consultants were covering the consultant gaps in the rota. Non-resident on-call staffing was planned for out-of-hour cover. The service were completing a business case to request additional funding to recruit additional medical staff and a consultant was waiting to be onboarded.

Children’s ED was staffed by nurses trained in paediatrics. Adult nurses with some additional paediatric competencies could be used to fill any staffing gaps. Staff told us they felt the department was also understaffed. For example, they said there could be up to 20 patients within the department with 2 nurses and the support of a health care assistant to provide care and treatment. The department did not always have an assigned consultant and relied on support from consultant in adult majors and the EPIC who were not paediatricians. They would call the paediatric specialist registrar for any urgent or emergency escalation where needed. Staff told us they felt that children’s ED was disconnected from the rest of the ED department, left alone and often forgotten about.

Not all staff were fully compliant and up to date with mandatory training. There were 34 separate elements that staff should complete with an 80% completion target for each. Nursing and medical staff were below compliance targets for multiple training elements, for example nursing staff were below for safeguarding adults level 3 at 54% and medical staff were below target for medicine management at 69%. Senior leaders told us nursing staff were given time to complete their mandatory training. However, staff said they used to get protected time, but this had now stopped due to demand for the service and low staffing. We were not assured that staff were maintaining the skills and knowledge needed to provide safe care and treatment and fulfil their roles.

Registered staff received revalidation checks, data showed both medical and nursing staff were 100% compliant with the professional regulating bodies, General Medical Council (GMC) and the Nursing and Midwifery Council (NMC)

All new staff complete an induction program which incorporated a trust wide induction and specialty orientation. Newly registered nurses were also enrolled into the Royal College of Nurses (RCN) preceptorship programme supported by senior nurses in the department.

Staff access to a Continuing Professional Development (CPD) programme which supported clinical competence and learning. Medical staff told us they have access to a medical application that consolidated organisational clinical guidelines, medication protocols and national guidelines. All staff spoken to said they had received a yearly appraisal. Data reviewed at time of assessment showed appraisal compliance rates were 80%.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

On the days of our assessment the department was found to be generally visibly clean, however we found the floor in Ambulatory Majors to be dirty. Oversight for area cleaning was inconsistent, for example, there was no clear cleaning schedule in Frailty S:DEC and the cleaning schedule for children’s ED was kept in a folder and had not been completed for the month of April. Cleaning records were clear in majors and S:DEC. We could not be assured that cleaning was being completed in all areas.

The trust used “I am clean” stickers where staff had cleaned equipment following its use. However, on the day of our assessment there was inconsistent use of this system, we were not assured equipment cleaning was being carried out in line with the services policies.

Staff were observed to be bare below the elbows. Handwashing facilities were available in all areas, however we observed some members of staff not washing their hands following patient contact. We requested data for hand hygiene audits for a six-month timeframe from November 2025 to April 2026. In this time compliance of 95% was only met twice. We were not assured leaders had oversight and monitoring of good hand hygiene practices in line with national guidance.

Staff completed mandatory training in IPC. Compliance rates varied from nursing to medical staff. Nurses had a completion compliance of 85% for IPC Level 2 with medical staff a completion compliance of 75% at the same IPC level. The trust target was 85%.

Domestic, hazardous and clinical waste bins were emptied and sharps bins were cleaned and labelled correctly. Personal protective equipment was available and observed to be worn when needed. Staff were able to tell us what they would do if a patient presented into the department with an infectious disease or transmissible illness for example Clostridioides difficile (C-Diff).

The Trust had an Infection Protection and Control (IPC) lead and referred to the National Infection and control Manual (NIPCM) for England for IPC guidelines. IPC was discussed at senior nursing forums, divisional senior leader meetings, staff meetings and in hospital infection control forums. The department had an action plan for IPC improvements within the ED. Staff training and hand hygiene were both areas where improvements were identified.

We scored the service as 2. The evidence showed some shortfalls. [BS1.1]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 visited all areas in the urgent and emergency care departments. We visited medicines storage areas and reviewed patient care records. We reviewed medicines audits, policies and procedures.

There was limited-service provision being provided by the pharmacy team to support Urgent and Emergency Care areas. This did not meet the recommendations set out in the Royal College of Emergency Medicine (RCEM) standards regarding pharmacy staffing and services in the emergency department. There was a clear process for staff to access medicines advice both during the weekday and outside of usual hours. The department was in the process of introducing a pharmacy presence to improve the pharmacy service to Urgent and Emergency Care.

Staff demonstrated an understanding of the importance of administering time critical medicines, such as those used for Parkinson’s disease but this was not consistently reflected in practice. We saw cases where medicines were not given on time and were missed.

In children’s services, staff weighed patients on arrival to support accurate dosing and used patient group directions (PGDs) safely, supported by clear training and appropriate checks. Staff in paediatric and emergency areas treated children promptly when they were unwell and followed appropriate pathways.

Medicines storage and the clinical environment did not always support safe practice. Some clinic rooms were messy, overstocked and disorganised. We found expired medicines and loose strips of medicines in some areas. Staff did not always complete daily checks as per local guidance of medicines storage areas, including monitoring expiry dates of medicines. Access to medicines storage was not consistently restricted to authorised staff, increasing the risk of unauthorised access.

Staff did not maintain full oversight of FP10 security and prescribing. Staff did not provide clear evidence of a robust system to audit all prescriptions issued which increased the risk of loss, misuse or inappropriate prescribing.
Allergy information was not completed, which can risk people receiving medicines that could cause them harm, and venous thromboembolism (VTE) risk assessments were not always recorded on patients’ records, which are necessary to prevent clot formation during inpatient stay. Staff did not consistently document the reason for prescribing medicines, including antibiotics, which limited the ability to review and monitor treatment effectively.

Staff did not use system alerts or prompts to identify when patients needed critical medicines in waiting and assessment areas. This increased the risk of delay to treatment, as patients could wait a long time without access to time sensitive treatment. Patients waiting for assessment may not have been well enough to recognise or explain their medicines needs, which further increased the risk of missed or delayed doses.

We issued a warning notice to the Trust for failing to meet the regulations relating to safe care and treatment with regards to medicine management.