Royal United Hospital Bath

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

This means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question as requires improvement. 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.

The service was in breach of regulation 12 for safe care and treatment and regulation 18 for staffing.

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.

Description: We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

Quality Statement Score: 2

We scored the service as 2. The evidence showed some shortfalls. The service did not always have a proactive and positive culture of safety. They did not always listen to concerns about safety. Lessons were not always learned to continually identify and embed good practice.

The emergency department’s (ED) culture supported safety and learning, but the challenges and pressures staff were experiencing did not always enable this to happen effectively. Overcrowding and staffing gaps created an environment where staff struggled to maintain their focus on long-term safety improvements.

The service demonstrated a reactive learning culture where improvements were inconsistent and not always upheld department wide. For example, recent monthly audits of fluid balance records identified inconsistencies in patient care and monitoring. While these findings suggested gaps in the consistency of documentation, it was important to note that these observations were derived from a 2-month data sample. In August 2025, a new fluid balance chart audit was launched following improvements to their electronic patient record system.

The service identified shortfalls with the monitoring and management of intravenous cannulas (plastic tubes inserted into veins), which is essential to prevent bloodstream infections. Although audits highlighted consistently poor performance, leaders did not always turn that data into lasting change. An action plan had been implemented to address this shortfall (including adding information to a learning poster and emails sent to nursing staff), but this was not sustained and did not result in improvements over time. This had a potential impact on patient safety as there was a risk of infections going unnoticed. However, we did see an example of sustained improvement following an investigation of a significant screening failure in late 2024, a targeted action plan was launched to improve the sepsis response. By the end of 2025, 100% of patients received their antibiotics within 1 hour.

The ED demonstrated a maturing safety culture by using the Patient Safety Incident Response Framework (PSIRF). Our review of 3 Patient Safety Incident Investigations confirmed the service translated some failures into effective learning. In one instance, a patient arrived with breathlessness and dizziness, but staff failed to escalate an electrocardiogram (ECG) finding that showed a heart attack. In response, the service launched an ECG interpretation competency assessment for ED clinicians to speed up reviews. Leaders applied the duty of candour in all 3 cases, ensuring patients and relatives received honest accounts and formal apologies. The duty of candour is the legal and ethical requirement for healthcare professionals to be open and honest with patients when something goes wrong with their treatment. This helped to create an improved culture of learning and ensured leaders investigated incidents thoroughly.

Staff were clear about what incidents should be reported and found the system relatively easy to use, however, staff told us they did not always have time to report all incidents due to the pressures of work. This meant there were missed opportunities for learning across the department and driving improvement around safety. When there were serious incidents or urgent concerns, staff said they were usually involved in any investigation and asked for their input. For example, clinicians used ‘hot debriefs’ (a short discussion immediately after a significant event) and ‘cold debriefs’ once the situation had resolved, to capture their reflections.

Communication of learned lessons from incidents remained inconsistent across the wider team. Feedback from incidents was via monthly emails from the investigating team, and safety briefings. Leaders acknowledged they had not yet identified the most effective process for ensuring learned lessons reached staff. However, the department had taken active steps to formalise and improve its oversight of mortality and morbidity to identify learning and drive improvement. Leaders held meetings 3 times a year and had launched joint case reviews with the Intensive Care Unit. The service also started an internal review of governance and reallocated consultant time to help increase the frequency of these sessions. These changes aimed to turn clinical reviews into more frequent, actionable service improvements.

Description: We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

Quality Statement Score: 1

We scored the service as 1. The evidence showed significant shortfalls. The service did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

While staff prioritised safety and continuity of care, the department struggled to maintain these standards consistently due to severe capacity pressures. While hospital services had expanded, some patients (particularly those with mental health needs) experienced long waits in the emergency department (ED) before they could be moved to the most appropriate setting for their care. Leaders recognised the risks associated with delays in transferring patients presenting with mental health conditions. It has been identified that external mental health service capacity remained a challenge. Leaders made it a priority to work with partners to support the transfer of patients experiencing mental health crisis to specialist services as quickly as possible. Multiple daily meetings were held with mental health partners to manage transfers and maintain situational awareness (tracking how many patients were waiting and why). Staff continued to escalate and advocate for this patient cohort; however, the lack of external mental health services meant these patients faced longer waiting times.

There were excessive delays with patients’ admission to wards which had a negative impact on the delivery of optimal care. Despite staff efforts, many patients stayed in the hospital longer than necessary because the outside support they needed wasn’t ready. On the first day of our inspection, 30 patients were waiting to be admitted to wards across the hospital from the ED, but there was no plan of where they would be admitted to. To manage this overflow, patients awaiting admission to a ward overnight were situated in the Urgent Treatment Centre (UTC), which was co-located for the treatment of minor injuries and illnesses. The department provided routine care for some patients in corridors because there were many patients waiting for ward admissions. This meant patients faced significantly higher risks due to prolonged waits and care being delivered outside of clinical areas.

Patients with both physical and mental health needs remained in the ED for long periods. In August 2025, 17.5% of mental health patients remained in the ED for over 12 hours. Although leaders told us there was access to mental health services 24 hours a day, this was provided remotely overnight from midnight to 8am, using a video call service. Staff stated this was rarely used or responsive, and most patients arriving in the evening would have to wait until at least the next morning to be seen. During our assessment, we identified an older patient who was in a small cubicle for 5 days waiting for a decision about their admission to a mental health bed. Staff identified that this presented a risk to the patient’s safety, wellbeing, and effective treatment. This was an ongoing risk as beds or community support for mental health placements (managed by another NHS trust) were scarce in the area and wider region.

The systems for streaming, triage and oversight of patients were not always operating in a timely way. Triage times in the department were not meeting the clinical guidance for triage which was to see all walk-in patients within 15 minutes of arrival. Data from October 2024 to October 2025, showed the service achieved this for 59% of patients on average. During our inspection, this system became disorganised when the rostered triage nurse could not be located by colleagues, resulting in a maximum wait time of 1 hour and 6 minutes; a delay staff were unaware of until it was flagged. There were procedures for extra triage to be organised when waiting times were escalated, but staff told us this was rarely acted on or achieved.

Some patients expressed confusion regarding their clinical pathway. Upon arrival, most walk-in patients were registered at reception and triaged by an experienced practitioner (nurse/paramedic) to ensure they were in the right place to receive care and treatment. However, there was then a further secondary triage stage for observations (for example, blood pressure and temperature). This multi-layered approach left patients unclear about their progress to receive care and treatment in the department. One patient reported being seen 3 times within an hour for repetitive questioning and testing, only to be returned to the waiting area without a clear plan. Another patient described being moved between different waiting zones, from the UTC to the ambulatory area, where they remained for over 2 hours without further communication.

Description: We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

While staff showed high levels of practical knowledge, formal training compliance was inconsistent across different staff groups. As of October 2025, medical staff achieved 100% compliance in level 2 children’s safeguarding, but nursing staff in the emergency department (ED) sat lower at 66.7%. While medical staff achieved 100% compliance for level 3 adult safeguarding training, nursing staff reached 72.58%. To address these gaps, the trust had an improvement plan. They scheduled monthly training sessions and sent emails to non-compliant staff and their managers as a reminder. By monitoring progress through the Vulnerable People Committee, the trust was on target to reach its 90% compliance by December 2025.

There were systems and practices to make sure patients were protected from abuse and neglect. The service operated under a legal framework that held staff accountable for the safety and wellbeing of all patients. The service based its safeguarding actions on the Care Act 2014 for adults and the Children Act 2004 for children. These policies focused on a multi-agency approach to protecting adults and children at risk of harm. The Vulnerable People Committee provided quarterly oversight and governance around this, and the service used a Clinical Governance and Adult Safeguarding Flowchart to link clinical incidents directly to safeguarding lessons. This helped to ensure reporting remained consistent across the NHS, police, and local authorities.

The trust had senior clinicians with responsibility for safeguarding of adults and children, and staff knew how to contact them. Outside of the safeguarding team’s core working hours, staff could access care plans and alerts via electronic patient records. Staff told us they felt comfortable speaking up if they had concerns about a patient or the person accompanying them. Staff in the ED demonstrated a good understanding of safeguarding and how to take immediate action when needed. Staff could explain that safeguarding meant protecting people from abuse and avoidable harm. They used a safeguarding screening tool for every child who entered the department. When a patient required a referral, the electronic system allowed creation of one based on the screening results. For example, clinicians completed a child protection referral for a patient they were concerned about to ensure immediate follow-up. This meant vulnerable patients were identified the moment they arrived, to help keep people safe.

Description: We work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

Quality Statement Score: 2

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

Risks were not always managed effectively due to persistent delays in transferring patients from ambulances into the hospital. While the department used a ‘Pitstop’ area for initial evaluations, this system was often overwhelmed by the volume of arrivals. Between September 2024 and August 2025, the emergency department (ED) received nearly 30,000 patient handovers from ambulance crews with an average wait time of 72 minutes. This was more than double the national average of 34 minutes. Nearly 40% of all patient handovers were over 1 hour of the patient arriving. This meant patients waited twice as long for hospital treatment which increased the risk of their condition worsening. Despite these systemic pressures, hospital staff accepted full clinical accountability for patients waiting in ambulances.

Staff told us they used body-worn cameras and had de-escalation training to manage the growing risk of violence and aggression, but there was no permanent security provision. Because of lengthy delays for admission to wards and other services, there were agitated patients in the same areas as frail elderly patients. During our inspection, a person who was acutely distressed due to a mental health crisis displayed behaviours that can challenge, including shouting and throwing a chair in a shared observation area. There was also a frail patient admitted with a head injury in this area. Staff reported that such incidents were common and gave further examples of a nurse being scratched and a doctor being assaulted with hot coffee. We raised this with the senior leadership team as a significant concern. As a direct result, the service deployed a permanent security presence in the department and a planned programme of training in de-escalation techniques to upskill staff. The aim of this was to ensure a safer environment for staff and a more protected space for vulnerable patients.

Leaders ensured every staff member, from nurses to consultants, could see a patient’s level of risk by displaying live National Early Warning Scores (NEWS2) on a digital whiteboard. The NEWS2 is a standardised tool used across the NHS to identify and respond to patients whose health is deteriorating. The system automatically displayed a red heart symbol next to a patient’s name if their warning score reached 5 or above. This meant staff could instantly identify who was the sickest and move resources to help them. Similarly, ED leaders monitored the time between a patient’s first vital signs (like pulse and blood pressure) and their sepsis screening.

The department followed professional standards to ensure patients were triaged based on their clinical urgency rather than their time of arrival. During our inspection, we consistently saw patients prioritised based on their needs. This approach helped to reduce the risk of staff missing a deteriorating condition in a busy environment.

The hospital had a Sepsis and Kidney Injury Specialist (SKIP) team and an Enhanced Care team to provide focused care for the most vulnerable patients. The Enhanced Care and Support team provided structured, therapeutic care across a range of observation levels, including one‑to‑one supervision, where deemed necessary and proportionate. Their role included continuous and cohort observation, active risk assessment, therapeutic engagement, de‑escalation, and close liaison with the department and specialist services. This model ensured that patients with complex physical, cognitive, or mental health needs received timely, proportionate support, while enabling the wider department to maintain safe care for general emergencies and respond quickly to deterioration. This shared responsibility helped to ensure the most critical patients received immediate attention, preventing their conditions from worsening.

The ED matron represented the service within the trust’s Deteriorating Patient Working Group, which met monthly. This collaboration brought together sepsis nurses and various service level leaders to share good practices and highlight areas for improvement. They used minutes and action plans to guide care for all deteriorating patients, ensuring that sepsis management stayed a top priority. This approach allowed the hospital to standardise escalation of care and maintain a focus on patient safety even during high-pressure months.

Description: We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

Quality Statement Score: 1

We scored the service as 1. The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

Overcrowding within the department created environmental risks and obstructed emergency access routes. There were multiple physical hazards, particularly regarding access to the children’s resuscitation area. This had worsened since the implementation of the ‘45-minute ambulance handover’ process. During our inspection, we saw 2 patient trolleys situated directly in front of the door to the children’s resuscitation room. These trolleys also obstructed a designated fire escape route. This blocked the primary access route for the resuscitation team in the event of a paediatric cardiac arrest, and placed children and young people at risk of harm. Staff members confirmed that they would normally divert an unwell child through the adult ambulatory waiting area (the back door entrance to the paediatric resuscitation room) because the main entrance was blocked. This rerouting delayed emergency care and compromised patient dignity. Following our inspection, the service took immediate action to clear these routes and implemented an action plan to ensure fire exits and emergency entrances remain unobstructed.

We observed clutter throughout the majors area such as linen trolleys, bins and chairs obstructing fire escape routes. We saw a fire escape route with a “Keep clear” sign was obstructed by staff sitting at a computer station. These concerns were immediately highlighted during and following our inspection and leaders responded quickly by clearing obstructions.

The department’s facilities for mental health patients were not consistently safe or suitable. There were several rooms and cubicles used to admit patients with mental health conditions which may be treated alongside any physical health conditions. The mental health assessment rooms conformed to some of the guidance from the Royal College of Psychiatrists as they were ligature free, had doors which were not lockable and opened both ways to allow safe access. However, the emergency department’s (ED) 2 mental health assessment rooms were non-compliant because they were joined by an internal door. They did not allow for observation of the patient from outside and were in a poor state of repair. The rooms were dark and we observed peeling paint and ingrained dirt on the walls. This did not provide a therapeutic space for patients experiencing mental health distress.

The Rotary Observation Unit was an unsafe environment for patients in mental health crisis because the service relied on individual staff members rather than a standardised safety system to manage ligature risks. The unit’s 8 bed spaces were not designed for mental health care, meaning staff had to manually remove equipment like oxygen tubing to make the space safe. On our first day, there were 7 patients in this area waiting for mental health placements. One patient we observed, who was at risk of suicide, still had easy access to oxygen tubing in their bedspace because it had not been removed. The hospital’s Enhanced Care and Support team consisted of Registered Mental Health Nurses, Enhanced Care Practitioners and Enhanced Care Support Workers. However, there was no consistent checklist to ensure bed spaces were made safe. This created an avoidable risk of harm which relied on staff’s experience to be aware of this risk, rather than a standardised environmental risk assessment tool. The trust had identified this and updated their ligature policy and operational guidelines. Following the inspection, the updated policy was immediately issued to the emergency department on 23 October 2025 and uploaded to the trust intranet. Additionally, the trust had invested in a lead nurse for mental health to oversee high-risk areas.

Severe overcrowding forced the service to provide care in corridors. On the first day of our inspection, there were 9 patients on trolleys in the corridor. Staff told us mobile patients could use the standard bathrooms, but those with limited mobility were taken to an assessment room should they need to use the bathroom. This meant the same room was being used for both personal care and clinical investigations, such as ECGs, which compromised the purpose of this space. We identified there was no standard operating procedure (SOP) for corridor care. This meant staff had no clear safety guidance to support, manage and risk assess the corridor care they provided. A standard operating procedure (SOP) was implemented on 24 October 2025 following our site visit. A SOP is a set of instructions created by organisations to guide staff on how to carry out routine tasks. Leaflets were given to patients to explain why they were in the corridor from 24 October 2025. There were no risk assessments to demonstrate that the 9 patients in the corridor were suitable to be there. However, we did note that these patients had stable observations, were not deteriorating, and received regular oversight from a designated nurse and support worker.

Despite the physical environmental shortfalls, the service managed its medical equipment effectively. There was a fully equipped and relatively new resuscitation area with closed bays (as it was built to deal with the Covid 19 pandemic). There was another separate resuscitation room for children. Equipment used to deliver care and treatment was safe and suitable for the intended purpose. There were resuscitation trolleys and emergency suction and oxygen located across the department.

Most patients were observed to ensure they were safe. There were numerous areas used for patients who were waiting for the next steps in their treatment or transfer. The main patient waiting area was overseen by reception staff who could see most of the room and there were cameras used for safety monitoring. Other areas where patients were waiting were in thoroughfares used constantly by staff and others, so patients were not hidden from view. In the Urgent Treatment Centre, patients were visible to staff who said they rarely closed curtains unless they were with a patient. Co-located services for patients were adjacent to the main ED areas. This included the X-ray department and other scanning facilities. There was a trauma assessment unit located close to the ED where patients could be directed as necessary.

Description: We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

Quality Statement Score: 1

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 department failed to maintain enough qualified and experienced staff to keep patients safe. There was a heavy reliance on temporary workers with high sickness levels, and unfilled vacancies.

The ED consistently did not meet Royal College of Emergency Medicine (RCEM) staffing guidelines. For a department of this size (approximately 77,259 patient attendances between January and September 2025), guidance recommends 2 to 4 Senior Decision Makers overnight. Medical staff told us they regularly worked nights with only 1 Senior Decision Maker, and our review of staffing rotas confirmed this. Leaders told us locum (bank) staff were sometimes used to fill gaps. However, this approach proved ineffective and we saw shifts were rarely filled - a concern that was consistently echoed by the staff we spoke with. When cover was secured, it often relied on staff who lacked the specific expertise required to manage complex emergency cases. We raised this as a significant concern, and the trust took immediate action following our inspection. To secure a safer workforce, leaders introduced higher pay rates for the 8 weeks following and began an urgent recruitment drive for permanent senior doctors with the support of the Chief Executive and the Integrated Care Board.

Nursing vacancies and sickness rates were identified by leaders as a primary concern. Vacancy rates consistently exceeded the trust’s 4% target. Registered nurse and healthcare support worker vacancies were both 13.39%. As a result, staff told us they were regularly pulled from their training days or from the children’s department to cover adult areas. Medical staff vacancy rates were recorded at 2.04%, which did not initially correlate with the medical staffing level of risk as identified on the risk register. This discrepancy existed because the baseline establishment required additional investment. Following the documentation of this risk, funding was secured, and the gap was being addressed with 7 Registrars scheduled to start in August 2026. Our review of medical staffing rotas noted a Registrar fill rate of 80.52% in October 2025. However, when considering medical staffing as a whole, the overall fill rate reached 95.1%. This was achieved through a strategy of over-establishing consultant roles to mitigate gaps found in individual Registrar roles.

Nursing staffing data showed significant shortages where the number of staff on duty rarely met safe requirements. Between July and September 2025, there was a 30% deficit in nursing hours, with permanent staff covering only 56% of shifts. To address these gaps, the service relied on temporary bank and agency workers, which increased the workload for the permanent team. Healthcare support worker coverage followed a similar trend where fill rates dropped from 82.5% in July to 73.1% by September 2025. Since the inspection, there has been a notable improvement in workforce stability. While the service previously struggled with declining coverage, more recent data shows staffing levels have reached a much safer threshold. For example, in March 2026, total fill rates rose to 95% for nurses and 93% for healthcare support workers. This was achieved by using bank staff to cover approximately 21% to 22% of the total planned hours. This meant there were more staff to provide care and treatment for patients.

A shortage of permanent nursing and healthcare support worker staff put patients at risk because not all temporary staff filling rota gaps were familiar with the department and how it operated. Rotas showed the skill mix of staff was not always as required and this was confirmed by staff. Staff who were not supposed to be providing direct patient care, known as supernumerary, were often needed to work with patients to cover shortages in nursing numbers, or stepped down from undertaking mandatory or other training. Staff would be requested from wards to help, although this had mixed success as ward managers were also managing their own staff shortages. The nursing staff shortage was on the department’s risk register and recognised as impacted by the high turnover of staff and the increasing demand for services and capacity problems.

To support gaps in staffing adult areas of the department, managers regularly redeployed children’s nurses to work in the adult areas. Staff told us this happened often. Staff also told us the nurse and healthcare assistant deployed to the corridor were pulled from their regular staffing numbers as they could not account for additional staff to cover this area. This meant other areas of the department were left short staffed regularly.

Sickness rates for nurses and support workers remained higher than the trust’s target. In the ED, sickness levels peaked at 8.81% in August 2025 and 8.79% in April 2025 for Emergency Medical Nursing. Appraisal compliance across all staff groups remained significantly below the 90% target, with medical staff showing the lowest rate at 61.54%. While nurses (71.77%) and healthcare support workers (66.67%) were slightly better, efforts to improve these rates were often undermined by high vacancy rates, staff sickness, and increased patient attendances. Although leaders had recently allocated dedicated time for senior doctors to support with reviews, this shortfall indicated that a large portion of the workforce was not receiving formal professional oversight or developmental support.

We observed safety huddles where staffing was discussed. These meetings lacked a clear structure and were poorly attended which meant the team could not develop effective plans to manage daily staffing shortages. Mandatory training compliance across the service did not meet the trust’s target of 90% compliance. As of September 2025, the average compliance score for medical staff across all mandatory training modules sat at 68.72%. registered nurses (RNs) and healthcare support workers (HCSWs) achieved slightly better compliance rates at 78.83%, and 75.38%. This meant the service could not be assured that staff had the right skills and knowledge to safely support patients. Leaders attributed these training shortfalls to operational pressures. To address this, the service introduced a recovery plan to protect training time and add extra sessions. Furthermore, the department has since introduced a robust supernumerary period for new starters and regular updates from the Clinical Practice Facilitators.

Operational pressures regularly impacted on training opportunities. While leaders valued education and learning, they sometimes had to pull nursing staff off their designated study days to cover clinical gaps in the department (due to low staffing levels). Managers told us training days were often cancelled to address workforce shortages. These cancellations prevented staff from engaging in the development activities designed to improve the service.

Description: We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

Quality Statement Score: 2

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.

There were shortfalls adhering to infection prevention and control (IPC) practices by staff. For example, we saw limited handwashing or use of hand gels from many staff on the first day of our visit. This improved when it was fed back to leaders as a concern. Staff did not always challenge other healthcare professionals in their department who were not following IPC or uniform policy. Some staff were wearing gloves to carry out procedures when gloves were not indicated (such as taking blood pressure) and not changing them in between treating patients.

The department was badly worn in many areas and parts were poorly maintained. While we observed domestic staff cleaning regularly, the ageing infrastructure which included flooring ingrained with long-standing dirt, meant many areas remained visibly stained despite their efforts. In clinical spaces, such as the plaster room, we found significant damage to plasterwork, peeling paint, and worn flooring. This meant surfaces were difficult to keep clean and increased the risk of healthcare associated infections. We further observed heavy limescale around sinks throughout which gave a poor impression, and in some areas, posters were stuck to walls with adhesive tape which was often peeling away. This meant there was a risk to patient safety as the environment did not support effective infection control processes.

Staff did not always maintain the barriers required to stop the spread of infection. For example, in the resuscitation area, staff left the door to an isolation room open, even though signage stated the patient inside was an infection risk. The designated emergency decontamination room (donning and doffing, adjacent to resus 5) was cluttered and used as a general storage area. This meant isolation measures could not immediately be performed when needed as equipment would have to be moved out of the way.

To address IPC shortfalls, the service implemented an improvement plan focused on increased clinical oversight and staff accountability. A central part of this plan was to ensure all IPC audits were conducted on an electronic platform. This helped managers move away from spot checking, toward real-time data monitoring. This improved oversight led to an increased compliance for ‘I am clean’ stickers on vital signs machines rising from 0% in May to 100% in October 2025.

The service demonstrated positive outcomes in other areas of IPC practice. For example, the Paediatric area looked visibly clean, with staff observed washing hands correctly before procedures and managing clinical waste appropriately. Patients were otherwise screened at triage or rapid assessment for markers of infection such as temperature and resistance to certain medicines.

Description: We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

Quality Statement Score: 2

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.

We reviewed 5 patient clinical records alongside inspections of controlled drug (CD) cupboards and resuscitation trolleys specifically across resuscitation and major treatment areas in the department.

We found that patients who stayed in the emergency department (ED) for longer periods were at an increased risk of receiving their medicines late, particularly time-critical medications. Data collected covering the period 4 January 2025 to 30 September 2025 identified that while standard medicines were given on time 89% of the time, time-critical drugs were given on time 74% of the time. With nearly 7,000 patients waiting over 12 hours, the department had found that these long stays led to fewer time-critical medications being administered within the safe 30-minute window. In response, the ED added this to their Risk Register for oversight purposes and launched a quality improvement project in October 2025 to prioritise medicines management during the initial triage process.

Inconsistent daily checks and staffing gaps weakened the oversight and monitoring of high-risk medicines. Audits identified missing daily checks for some controlled drugs cupboards and resuscitation trolleys. The department recorded ‘unaccounted for’ controlled drugs losses every month, with 3 incidents in August 2024, March 2025, and August 2025. Additionally, pharmacy coverage was limited to 4 days per week with no weekend presence, which reduced the level of professional oversight for medicine reconciliation. This was not in line with Royal College of Emergency Medicine (RCEM) guidelines in relation to pharmacy cover across an ED. To manage the risks, the department mandated a senior nurse (Band 6 or above) must participate in every controlled drug administration.

Despite these challenges, the ED had secure storage systems and maintained clear clinical guidelines. The installation of automated cabinets provided secure storage with digital audit trails for most medicines. Policies for sepsis, antimicrobial use, and rapid tranquilisation remained easily accessible to all staff. The trust initiated a Controlled Drugs Assurance Group that met monthly to review every discrepancy and identify trends. The use of automated cabinets helped to reduce the risk of manual documentation errors and improved overall drug security. The monthly governance meetings ensured the department remained accountable and could quickly address any sudden increase in medication incidents.