The Ipswich 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 patients were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked patient’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. At this assessment, the rating remained requires improvement.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff were able to raise concern verbally to leaders but did not always follow this with a written incident record. Leaders listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. However, the service did not always manage or monitor people’s safety. They did not always make sure patients were monitored and observed in line with trust policy or national guidance.
The service did not always work well with people to understand what being safe meant to them and how to achieve that. They did not always concentrate on how to avoid harm and neglect. They did not record clinical escalations and concerns appropriately.

Staff tried their best under increasing pressure and demand on the service to provide care and meet people’s needs. The service made sure there were enough qualified, skilled and experienced staff, who received effective support and development. They worked together well to provide safe care that met people’s individual needs where possible.

The service did not always detect and control potential risks in the care environment. They did not always make sure facilities, and technology supported the delivery of safe care. They monitored the risk of infection and had policies and procedures in place to help control the risk of infections spreading, however staff did not always adhere to them.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involve people in planning, including when changes happen.

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.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff were encouraged to raise concerns and able to tell us how to record incidents on their internal system. They were confident senior leaders would treat them with compassion and understanding. Where lessons had been learnt from incidents learning was shared with the Urgent and Emergency Care (UEC) staff. Leaders held focused teaching sessions for staff if concerns or incidents were raised and gained support from clinical specialists to facilitate training for staff. Leaders listened to concerns about safety, investigated and reported safety events. For example, there had been concerns raised around safety in the waiting room, as a response, leaders had allocated a permanent member of clinical staff to maintain oversight of patients waiting in this area.

However, staff did not always complete an incident form for all concerns or incidents verbally raised. Leaders told us staff did not always have clear guidance on what would constitute a reportable incident, this meant there were not always clear records of incidents themes across the department. For example, when risk assessments were not completed appropriately or delays in patients seeing specialist teams.

Leaders carried out daily huddles at the beginning of each shift for both medical and nursing staff. Information shared included learning from incidents, recent safety alerts and details of operational demand. However, administration staff told us they would benefit from being included in these daily huddles and often did not feel part of the wider emergency department team because of this.

Staff we spoke to understood the need to be open and transparent when things go wrong. They told us they had access to the duty of candour policy which was in date and version controlled. Duty of candour is the legal and professional responsibility for healthcare providers to be open and honest with patients, and their families, when something goes wrong with their care that has caused, or could have caused, harm or distress. This may include, offering an apology, and explaining the incident and its consequences. Staff told us they would be supported by leaders when mistakes happened and supported to learn from incidents.

We saw the trust wide complaints and concerns handling policy which was in date and version controlled. We reviewed 3 complaints from Urgent and Emergency Care for adults which were managed within the timescales in line with trust policy. We also reviewed 3 complaints from ED Paediatrics which is managed by the Women and Children Division. These were also managed in line with trust policy and responded to within the allocated timescales. The service shared investigation findings and were open and transparent where failings had been identified. They shared areas of learning and gave assurances to the complainant that action would be taken to prevent errors occurring again.

Complaint and incident themes were shared at monthly divisional board meetings. Complaint examples were shared in detail with board members and assurance given around lessons learnt and ongoing monitoring. Identified actions were added to the divisional action log with clear timeframes of completion. At time of assessment the top 3 complaint themes over the last 3 months were, access to treatment or drugs, waiting times and communication.

These themes were reflected during our assessment. People using the service told us they were not always signposted to give feedback on their care. During our assessment the department lacked visible prompts for patients and relatives to give feedback on their experiences and staff told us they were unsure how to signpost people. Our previous assessment in 2020 also highlighted the service did not ensure patient feedback was actively captured within the department. Leaders told us they had posters for giving feedback on care but acknowledged that there was a need to improve methods in collecting patient experience feedback.

The service mostly worked well with people and healthcare partners to establish and maintain safe care. Safety and continuity of care was a priority throughout the patient’s journey, but this could be impacted at times of high demand on the service.

People would enter the department either through the public main entrance or via ambulance entrance. Patient streaming processes at the front door was working well although when demand increased we saw patients waiting for triage spaces to become available. Flow and capacity into the department remained a continued concern to leaders and staff. They told us the public entrance and rapid ambulance triage (RAT) in the ambulance entrance was being closely monitored. A streaming system was in place which enabled patient to be seen in the most appropriate place within the department. This could be either to see a General Practitioner (GP), paediatrics, minor injuries, majors department or the resus area for the most unwell patients

Leaders met multiple times a day to discuss and manage service capacity. They told us they were continually adapting processes to meet demand and maintain patient safety. However, staff told at times these changes would happen without them being aware and were not always kept informed of the reason for the changes. The children’s emergency department had its own waiting area, separate from the main ED waiting area that was monitored by paediatric nursing staff.

We reviewed the patient flow and escalation policy and procedure which was in date and had been verified. The policy was in place to deal with the fluctuations in demand and capacity so that any associated clinical risk could be managed. However, patients who had been admitted to the emergency department with both physical health needs and mental health needs would at times stay in the department for too long. At the time of assessment, we saw multiple patients who had been in UEC over 20 hours awaiting discharge or admission to a ward. Over the past 3 months department capacity and extended length of stay had been reported once despite ongoing challenges with demand and flow within the department.

The risk of poor flow through the department had been on the trust’s risk register since 2017, there had been several actions and reviews carried out of UEC procedures during this time. However, the risk still remained high on the register and additional actions were being implemented but not sufficient improvement to reduce the risk rating.

Initial 15-minute triage times for adults were below the trust target of 90% between March and August 2025 and for children on average over the last 12 months were triage on average within 16.4 minutes. However, data for the same time period showed children would be waiting on average 122 minutes to see the first clinician following triage. This was not in line with the trust target of 60 minutes.

People who required specialist review within UEC were not always seen within the 4-hour national target. Staff told us there were certain specialty teams that did not carry out a face-to-face review of patients in UEC, this often led to delays and poor continuity of care when patients moved to the wards. Leaders acknowledged that there was work needed to ensure patients received a timely specialist review whilst in UEC as this was impacting on prolonged wait times.

On our previous assessment we found staff did not keep detailed records of patient’s care and treatment. Paper records were not always clear and up to date. We saw similar themes during this assessment. The service did carry out some care record audits, but this did not include observation audits. Care records we reviewed showed missing mental health risk assessments, mental capacity assessments not being completed and clinical observations missing. The service did not always ensure that accurate, complete and contemporaneous records including clinical escalation, and/or care and treatment that were provided. This meant patients were at risk of not receiving the necessary care and treatment in a timely way.

Leaders acknowledged this area of risk and had planned additional training for UEC staff. The trust were also awaiting the implementation of a new electronic patient record system service wide. They told us this would allow for greater continuity of care and reduce risk of missing documentation. This was due to launch the week beginning 29 September 2025.

Staff did their best to manage the continuity and transition of peoples’ care. They told us teams worked well together to deliver safe care but would be under additional pressure at times of high demand. Staff we spoke to were patient experience focused. However, people did not always feel informed about their care. They told us staff did not always update them when long waits occurred.

People attending Urgent and Emergency Care (UEC) were booked into the services computer system. Administration staff told us they had robust processes for checking any child or women of childbearing age who attended for safeguarding concerns. Nursing staff told us they would if necessary complete any adult checks post triage process. For both adults and children any safeguarding alerts would be flagged on the digital system alerting staff. This process was in line with trust policy.

The service had safeguarding policies and procedures that were date and version controlled. Staff in paediactric UEC were able to demonstrate a good understanding of child safeguarding processes and had clear lines of escalation when they were concerned. In adult UEC there was an understanding of safeguarding including who to contact, how to complete referrals and how to take appropriate and immediate action when needed.

Staff compliance with safeguarding training did not always meet the trust target. We reviewed UEC compliance for safeguarding training. The department was below the trust target of 90%, with only 53% of medical staff completing safeguarding children level 3 training and 72% completing safeguarding adults level 3 training. Nursing staff had met the trust target of at least 90% compliance for safeguarding adults level 1 to 3 but were below target compliance for safeguarding children level 3 at 88% compliant. Leaders told us there had been a halt on training recently due to the implementation of their new electronic patient record system. Low medical staffing compliance was noted on the providers Safeguarding Families and Complex Health Divisional report for the Medical and Community group action plan. There was an improvement target date set for November 2025 however, it was unclear what actions were being taken to improve training compliance levels.

Staff were aware of the level of safeguarding training they had completed. Reception staff we spoke with told us they had also completed safeguarding training and would escalate any concerns to nursing staff. Training data provided showed administrative and clerical staff had met the training compliance for adult and children safeguarding level 1 training.

Mandatory training data provided showed that the service did not include training for consent to care and treatment, Mental Capacity Act (MCA), or Deprivation of Liberty Safeguards (DoLS). These are legal procedures designed to protect people who may lack the capacity to make decision about their care and treatment in hospital. They ensure any restrictions on a person’s liberty are in their best interests and are the least restrictive way to ensure their safety. Leaders told us there had been targeted training over the past 18 months for MCAs and DoLs. However, had concerns these processes were not fully embedded with staff and told us further face to face teaching sessions for staff were planned for October, November and December 2025.

Data submitted showed safeguarding was discussed at daily shift huddles and staff confirmed learning from safeguarding incidents was also shared. Senior leaders met quarterly to discuss safeguarding concerns through their divisional board meetings. These meetings were documented and had associated action logs.

At our previous assessment it was found that staff did not always identify and quickly act upon patients at risk of deterioration. Early warning scores were not always taken and acted upon correctly. Patients were not always monitored appropriately. Patient observations were not always undertaken when required and were not always escalated for clinical review.

During our recent assessment we saw similar themes of concern. The service did not always work well with people to understand and manage risks. The service did not always monitor patients within the department that were at risk of deterioration. Current systems used lacked consistent oversight to ensure staff were reviewing patient’s National Early Warning Score (NEWS2) and Paediatric Early warning Score (PEWS) to detect and respond to any clinical deterioration. For example, during assessment we witnessed an adult patient who was at high risk of deterioration was not being appropriately monitored. On review of the patient care records its showed multiple high NEWS2 scores that had not been escalated in line with trust policy or the Royal College of Physicians National Early Warning (NEWS)2 Standardising the assessment of acute-illness severity in the NHS.

Data requested also showed there were gaps in monitoring clinical observation compliance. Audits regarding NEWS2 observations had started in June 2025. These audits showed patients across all areas were having observations recorded a minimum of 2 hourly in line with trust policy and patients at point of triage were being checked for sepsis and escalated appropriately. However, once patients were in the department there were delays in patients having timely observations carried out and care records lacked documentation of high NEWS2 escalation. Audits data provided also showed patients were not always having a fluid chart started where the NEWS2 score was 5 or 3 in one parameter-unless septic and treatment escalation plans were not routinely started for patients with a NEWS2 of 7 or more as per trust policy.

We requested evidence of incidents reported in the last 12 months. This data showed that staff had documented 4 incidents where NEWS2 scores had not been completed in line with trust policy. These incidents had been graded as low physical harm. The incident data submitted did not align with the gaps in NEWS2 audits which highlighted that staff were not always reporting when observations are missed.

On review of the PEWS audits data from May 2025 to September 2025 showed some low compliance. Some children would not have their blood pressure taken within 2 hours of their attendance, and PEWS scores were not always calculated and documented in line with trust policy. There were also gaps in audits with the month of June 2025 showing no data at all. Following our assessment the service submitted additional evidence showing audits were completed for June 2025. There had been delays in data validation of this audit process.

Staff and leaders, we spoke to acknowledged NEWS2, PEWS and sepsis monitoring during admission within UEC could decline and this was not in line with trust policy or best practice. They did have a sepsis champion in place but often due to high demand on the service observations might be delayed or missed. They also acknowledged that documentation of concerns and high NEWS2 escalations needed improvement. Leaders gave some assurances regarding the new electronic patient record systems due to be launched a week post assessment. This new system had been designed to give visual prompts to staff when observations were due or observations showed a patients deteriorations. Leaders also told us they would be able to carry out real time audits which would enable them to be more responsive to any themes and trends within the department.

Data reviewed also showed that the service was not always meeting its 15-minute triage target. between March and August 2025, Ipswich Emergency Department did not achieve the trust target of ensuring that 90% of triage observations were completed within 15 minutes of arrival. During this period, compliance ranged from 64% to 88%. This is a nationally set target of 90% and NHS trusts must submit ongoing data to a national dashboard. Triage staff told us they had been working closely with leaders to continually adapt and modify the front door triage process but were restricted for space and the area being used at the time was not suitable to meet the demand. We requested incident information where a delay in triage had caused harm in the last 12 months. The service told us there have been no harm caused from delay in triage processes.

The service used a sticker system to identify medical alerts for patient records. This included diabetics, falls risk patients, dementia and Do Not Attempt Cardiopulmonary Resuscitate (DNACPR). On review of patient records these alerts were not always present on the appropriate patients notes. This meant staff were not always made aware of current patient risk. Data requested also showed the service did not carry out compliance monitoring of this risk alert system and its effectiveness.

During times of high demand, the service would utilise corridor space for patients who had been seen by a doctor and either awaiting a bed on a ward or discharge. The maximum capacity for corridor care was 8 patients with an allocation of 2 staff. Staff had a risk assessment and suitability criteria to follow when allocating patient to this space. However, review of incident data showed 3 incidents reported in the last 12 months where patients had been allocated to a corridor space before seeing medical staff and without the necessary risk assessment being completed. The incident was graded as low or no harm and action had been taken following escalation to leaders.

During assessment we observed patients in the corridor had access to call bells and drinking water. At time of assessment, we witnessed staff carry out this risk assessment process which took into account the patients presenting complaint and any risk of deterioration. Staff working within this corridor space had been given additional training to monitor these patients and completed an additional observation chart alongside an Extended Length of Stay Checklist. However, data requested in relation to corridor care audits showed leaders did not monitor the completion of these proformas and were unable to demonstrate their effectiveness. We reviewed incident data from the previous 12 months which showed there had been 3 incidents relating to extended length if stay.

The service had policies and procedures in place to support people who may present to UEC in a mental health crisis or complex needs. Pathways for referrals to mental health liaison teams were utilised by staff on initial triage, however continued monitoring of this risk whilst the people remained in the department was not consistent. Records reviewed showed patient with history of mental health and self-harm were not always risk assessed, and relevant documentation completed in line with trust policy.

We requested evidence the service had implemented Martha’s Rule. Martha’s Rule is a patient safety initiative to support the early detection of deterioration by ensuring the concerns of patients, families, carers and staff are listened to and acted upon, Ipswich Hospital was one of the early adopters in May 2024. The service provided their “Call 4 Concern” standard operating procedure which had been approved after our assessment date. The operating procedure only covered adult inpatients. We were not assured the service had fully implemented the national recommendations as set out by NHS England.

The service did not always consistently use the required risk assessments and care documents to maintain good care. For example, we found out of the 16 occupied cubicles in majors none had fully completed rounding forms. Rounding in the NHS refers to a structured process where nurses conduct regular checks with patients to address their needs. There was also a lack of venous thromboembolism (VTE) risk assessment being completed despite patients being in the department for a prolong period of time, who might be at risk of developing VTE. Leaders told us the VTE assessment would be carried out within 4 hours by the specialist teams that the patient might be referred to. However, the service was unable to provide evidence these assessments were being carried out within the time frame. They did not audit this process, and the service lacked effective monitoring to ensure compliance was being met.

People told us the department was clean, light and calm. They told us the new environment was an improvement on the Urgent and Emergency Care’s (UEC) previous location within the hospital. Some people told us the public waiting room could become crowded at times and seating was an issue. Staff told us they had access to additional waiting area at times of high demand, but this was only available during daytime hours. If this area was utilised additional staff would be allocated to monitor patients.

Parents within the paediatric department told us the area was clean and child friendly. Children and young people had access to an enclosed indoor play area, and the unit was security system controlled by UEC reception staff. The unit had 6 cubicles, 1 of which was specifically designed for children and young people with mental health and additional needs.

The main major’s area was a bright and calm environment. Each patient had their own cubical with integrated clinical monitoring equipment. The cubicles were glass fronted with sliding glass doors that enable line of sight for nursing staff. There were accessible toilets and shower rooms for patients. Staff told us other areas were not always suitable to meet patient’s needs.

Staff within the Ambulatory Emergency Care Unit (AECU) told us patients had long waits in uncomfortable chairs and had to walk down the corridor to use toilets. They told us this was escalated to leaders, but they had limited action due to the estate layout.

Daily safety checks of specialist equipment including equipment on resuscitation trolleys were completed in all areas of the emergency department. Fire extinguishers were all checked and within expiry dates. Staff had received fire safety training as part of their mandatory training. On review of local fire safety training compliance data, nursing staff met the target of 90% (97%) but medical staff were below target at 66%.

The service did not always detect and control potential risks in the care environment. Within majors there were 2 additional rooms (cubicles 18 and 19) that were out of sight from nursing staff. Staff explained that these rooms were “ligature light” rooms and en-suite bathrooms that were used for any mental health patient who posed a potential self-harm risk. They also told us they had a closed-circuit television (CCTV) monitoring system in place and that the monitor screen was visible in majors. However, there was no clear signage or evidence within patient notes that patients had been informed they were being watched through CCTV.

During our assessment we observed 2 patients that had be allocated to the ‘ligature light’ rooms as they required closer medical observation. Both patients had not received any form of risk assessment prior to be placed in these rooms. We escalated our concerns to nursing staff at the time of the assessment and the patients were promptly moved to a more suitable cubical.

Following our assessment, we sought clarification around these 2 rooms. We requested evidence of current risk assessments, guidance and video surveillance policy in line with the Health and Social Care Act and the Regulation of Investigatory Powers Act (RIPA) 2000. This was not provided. We were not assured the service was taking the necessary steps to ensure only clinically appropriate patients were placed in rooms 18 and 19 and that video surveillance was being used in accordance with regulations. After raising our concerns the service told us they had removed the camera's entirely.

There was a fully equipped resuscitation room and staff told us they had the equipment they needed to keep patient safe. Equipment used to deliver care and treatment was safe and suitable for the intended purpose. There was strategically sited emergency equipment, such as resuscitation trolleys, emergency suction and oxygen across the department and staff could tell us where the nearest equipment was located.

During this assessment we saw that leaders ensured there was always enough qualified, skilled and experienced staff to safely manage the department. At times of high demand, they would utilise bank and agency staff to fill staffing gaps. The service had additional Urgent and Emergency Care (UEC) induction programme for new, bank and agency staff along with a check list of training compliances prior to commencing their first shift.

People told us although the department was busy there was always a member of staff accessible to ask for help. They said staff were working very hard to make sure people had care given and access to food and water. People in the main waiting area told us having a Health Care Assistant (HCA) in the public waiting area provided assurance and comfort.

Staff we spoke to understood their roles and responsibilities within their scope of practice. They told us if they felt a task was outside of their training they would escalate to the nurse in charge for support. Staff told us the paediatric department was mainly staffed with paediatric trained nurses or adult nurses with additional paediatric training.

Data reviewed showed the planned vs actual staffing numbers within UEC between June 2025 and Aug 2025 staffing cover was at 96% and on average the fill rate for staff was 100%. We also requested current vacancy rates for UEC. The trust target was 3.5%, however nursing vacancy rate was 11% and HCA were around 12%. Medical staffing vacancy rate was -11.8% in August 2025 which showed they were over staffed based on the whole time equivalent. We also reviewed the workforce future planning for the service. This was a trust wide document and did not outline how staffing within UEC was going to be maintained and enhanced in the future.

Staff told us they were up to date with their mandatory training but also commented that most training had been cancelled recently due to staff being required to complete digital training for the new electronic patient records system. Mandatory training data showed 32 separate elements that staff were required to complete, the trust target was 90% completion for each element. Overall mandatory training rates for the division were 91%, however a detailed review of UEC data showed that medical staff were consistently below completion target. For example, for adult basic life support only 39% of medical staff had completed this training compared to 78% of nursing staff and only 62% of medical had completed their sepsis training compared to 97% of nursing staff.

Leaders we spoke to acknowledged that mandatory training was a challenge due to demand on the service. Nursing leaders recognised the barriers and were working with consultant leads to address the low compliance amongst doctors. However, at time of assessment we were not assured all staff had received the most up to date training and were not always compliant with mandatory training requirements.

All staff we spoke with told us they received regular review of their work in the form of an appraisal. They said this was an opportunity to speak about development and raise any concerns. They were supported to make quality improvement suggestions and told us they were valued by their managers. Data reviewed showed appraisal compliance rate of 89% near the trust target of 90%. Leaders we spoke to outlined the importance of staff engagement and development. They encouraged staff to make suggestions for care quality improvements and understood the service pressure staff faced.

We scored the service as 2. The evidence showed some shortfalls.
People using the service told us the department was visibly clean, and cleaning staff were active in all areas of UEC. They told us the new building was a lot calmer than UEC’s previous location. They said they saw staff using hand gel and washing their hands before care and treatment.

On the days of our assessment, we found the departments to be visibly clean in all areas. Domestic, hazardous and clinical waste bins were emptied regularly, and sharp bins were clean and labelled correctly in line with trust policy. The service outsourced their cleaning contract to an outside company. Cleaning staff told us they had clear cleaning schedules throughout their shift and would respond to any immediate infection prevention control (IPC) risks within the department.

Staff working in the main entrance triage area told us they had raised concerns about potential IPC risks. The area was carpeted and had no handwashing facilities for staff. This had been escalated to senior leaders and had been added to the UEC risk register. Leaders told us this area was not purpose built for triage but had been adapted to meet demand and enabled patients to be clinically assessed and triage as soon as they walked into the department. For the interim and to help mitigate IPC risk staff had access to hand gel and additional IPC equipment, cleaning of this area was also carried out throughout the day, but leaders acknowledged that a longer-term solution was needed.

We requested evidence of any IPC audits carried out within UEC. The service explained that there had been a recent change in cleaning contractor. They had been working with the new provider and cleaning audits were undertaken in line with the National Healthcare Cleaning Standards. Audit information provided for June 2025 to Aug 2025 showed good overall compliance with only 3 occasions where compliance dropped below the 95% target.

Equipment cleaning within the department was the responsibility of nursing and support staff as per trusts Routine Decontamination of Clinical Equipment in Wards and Departments V2.0. The policy gives clear detail and guidance on how staff should clean each piece of equipment and which cleaning product to use. During our assessment we did not see “I am Clean” stickers on any medical equipment so we were not assured equipment was being regularly cleaned in between patient contact. IPC leads told us this had also been highlighted as an area of improvement prior to our assessment. They told us they had been working with nursing staff to establish a consistent process for cleaning equipment that was effective.

During our assessment we observed staff were not always washing their hands following patient contact and on one occasion a staff member attended 5 patients without washing their hands between. Also, not all staff were bare below the elbow in line with trust IPC policy and NHSE national infection prevention control guidance. Following our assessment, we requested hand hygiene audits. Data shared showed from March 2025 to August 2025 UEC overall had met the trust target of 95% compliaint with an average score of 99%

Leaders told us they would identify any patients within the department who were tested as positive or showing signs of infection and they worked closely with the hospital laboratory teams. These patients would be isolated as soon as possible and infection risk noted on their care records. Each cubical in majors could be used for isolation as they were individual rooms with sliding glass doors. Staff had access to additional personal protective equipment such as gloves, aprons and masks. During assessment we observed clear signage on cubical doors to indicate the patient was under isolation and additional personal protective equipment was needed.

The service had a current Infection Prevention Control Procedure document that was in date and version controlled. Staff had access to this document via the internal internet system.

People told us that they were given information about their medicines and received the medication they were prescribed. This was recorded in the prescription charts. Patients were also provided with information about treatment they had received which was provided via patient education counselling and patient information leaflets. Patient’s documents recorded allergy status clearly and they also received colour coded wristbands to indicate allergy status to staff.

Staff (including agency staff) received medicines training and were assessed as competent to provide medicines support to people. Staff told us that a pharmacist was available to support the ED and that they were responsive to queries. They were also contactable out of hours via an on-call service. Staff we spoke to understood how to access relevant local medicines policies, procedures, and guidelines. Staff told us that medication incidents are discussed regularly within departmental meetings and learning is shared trust wide with support from trust Medication Safety Officer (MSO) and pharmacists.

During our assessment we found that medicines were stored securely in line with national guidance. We saw some medicines were stored in easy to reach places. Emergency medication was available, daily audits were carried out to checks the contents of the trays. The department had prepared To Take Away (TTA) packs of medication which could be given to the patients to avoid delays in discharge.

Medicines, including controlled drugs, were disposed of safely when no longer required and suitable records made. Medical gas cylinders such as oxygen were kept secure and in a safe position. Empty cylinders were kept separate and appropriately monitored. Medicines dispensing locations and equipment used to prepare medicines such as tablet crushers and cutters were cleaned regularly.

Audits demonstrated that medicines were managed safely, such as medicines reconciliation, missed and delayed doses, relevant patient safety alerts. Medicines were given as prescribed, following national guidance and /or local policy and in line with legislation. Medicines were mostly accurately reconciled and recorded on admission.