Frimley Park 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

In our previous assessment, we rated safe as outstanding. At this inspection, we rated safe as good. We assessed eight quality statements.

In our assessment of Urgent Emergency Care (UEC) services we found there was a positive learning safety culture where events were investigated, and learning was shared and embedded to promote good practice. Staff we spoke with were open and honest when things went wrong, and they had the opportunity to learn and gain experience. The environment was safe and well maintained. Staff practiced high standards of infection prevention and control. Risks to patient safety were mostly mitigated. However, risk assessments were not always completed. There were effective mechanisms to adjust staffing levels when needed to keep the department and patients safe. Staff mostly demonstrated safe medicines management. However, patient records we reviewed did not always demonstrate a documented timely assessment of skin integrity.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff and leaders we spoke with were aware of NHS England best practice guidance: Learn from Patient Safety Events (LFPSE). They told us they were encouraged and supported to raise concerns, and felt confident that they would not be blamed, or treated negatively if they did so.

In April 2024 the trust transitioned to the NHS England's Patient Safety Incident Response Framework (PSIRF). This meant the trust focused on effective learning and compassionate, meaningful engagement with those affected when incidents occurred. The trust has 4 medical consultants who have dedicated time within their job plan for patient safety clinician activities and responsibilities.

There was a culture of safety and learning. Safety events were analysed, investigated, thoroughly, and lessons were learned to continually identify and embed good practices. For example, staff told us about the changes to practice following a Never Event relating to a wrong sided pain nerve block. A nerve block is an injection that may provide temporary pain relief.

Information provided by the service demonstrated that learning had been taken and shared with staff following incidents within the department. We reviewed learning responses resulting from patient safety events which demonstrated a good level of family and patient involvement in the investigation of patient safety events. Families and patients were given the opportunity to ask questions as part of the investigation. Patients and their families received copies of the final report.

Staff at all levels had a good understanding of how to use incident reporting systems and what to report. The trust successfully implemented a new electronic incident reporting system in 2024.Data showed no decrease in the number of incidents reported since the implementation.

Data provided by the trust showed between June 2024 and January 2025, a total of 873 incidents were reported. The top three themes for incidents reported were in relation to: access, admission, transfer, discharge (including missing patient), behaviour / violence and aggression and pressure ulcers.

Leaders could articulate the themes and trends of incidents, the action they had taken to address these, and the methods used for feeding back to staff. For example, a thematic review was currently being undertaken in relation to a theme which identified delays in escalating abnormal laboratory results.

There were several ways that learning was shared across both the service and trust wide. These included safety alerts encrypted electronic messages, safety huddles, handovers, safety snippets, patients safety briefing forums, patient stories and posters on the back of staff toilet doors. There was a central log of National Patient safety Alerts, which were shared with staff and actioned as appropriate.

The service used the learning from complaints and concerns as an opportunity for improvement. Senior members of staff and leaders were involved in reviewing complaints and incidents. For example, a leader within the Emergency Department (ED) told us that there had been a theme of complaints relating to the lack of access to hot food whilst in the ED. In response to this mobile tables had been ordered that went over trolleys to enable patients to safely eat hot meals.

Data provided by the trust showed between June 2024 and January 2025 there were 42 complaints received. Of those closed, 91% were closed within the agreed timescales set out in the trust's policy. The top three themes relating to complaints were communication, clinical treatment and patient care.

The department worked collaboratively with internal colleagues and external partners to maintain patients' safety. Continuity of care was maintained by effective handover of patients and communicating their individual needs.

Alerts on the electronic patient record enabled staff to be aware of and follow specific care plans if a patient had needs that required additional support. For example, there were monthly multi agency meetings which included, adult social care, the ambulance service, police and primary care to discuss and formulate bespoke care plans for patients who attended the emergency department often. The bespoke care plan was stored on the patient's electronic patient record which other agencies could access. This was in line with The Royal College of Emergency Medicine (RCEM), Best Practice Guideline, Delivering Interventions and Services for High Intensity Use Frequent March 2024.

Patients could access emergency support at any time of day or night. Patients were satisfied there was a joined up, collaborative approach to safety that involved them and their loved ones. They understood their pathway of care and had been informed throughout. We observed staff apologising to patients for any delays.

Staff adhered to safe systems and processes to deliver care. Staff mostly completed risk assessments, and any identified risks were mostly managed appropriately.

The service had a policy which outlined that a care plan should be completed for each patient when they have been in the department for 6 hours and every 6 hours thereafter. The electronic records system prompted staff members every 6 hours to complete the care plan. The care plan included pressure areas and falls risk assessments. We reviewed records of 5 patients, all over the age of 70, and found that none of these patients had a pressure area assessment documented as part of the initial care plan assessment. One of the 5 patients did not have a pressure area assessment documented until 18.5 hours after initial assessment. This meant there was a potential delay in recognising, managing and preventing deep tissue injury.

There were two senior nurses at the entrance of the ED who assessed and directed patients, depending on their acuity, to an appropriate clinical pathway or department. Patients could be streamed to the medical, surgical and acute frailty same day emergency care (SDEC) departments and urgent treatment centre (UTC)Patients could also be referred to the acute frailty team and gynaecology team pathway where required. Children and young people were directed to the Children's ED.

The service had 24-hour access to mental health liaison and specialist mental health support for adults, children and young people. There was a good working relationship with the local mental health liaison teams.

The ED had a clear pathway for supporting people with mental health needs. During triage, nurses complete the Mental Health risk assessment, grading risk as low, medium, or high with attached guidance on supporting patients at each level of risk. The trust's RCEM audit showed this risk assessment was completed for 91% of patients in 2024.

The psychiatric liaison team was working towards a CORE24 model, but it was not funded to deliver this fully. At night the team only had one practitioner working. The psychiatric liaison team responded to most urgent and emergency requests within one hour. For example, data showed in December 2024, 96% of patients were seen within 1 hour. CORE24 is a National 'best practice' model of care for Liaison Psychiatry which seeks to improve patient care.

There was a Children and Young Peoples Services (CYPS) Paediatric Liaison Service called Core 13 Service. Core 13 Service ensured the needs of the Children and Young People (CYP) presenting at ED with mental health and emotional issues were met in a timely manner. Staff comprehensively assessed, planned and facilitated safe discharge in conjunction with the CYP and their main carer/s. The Core 13 Service was called as such because it had an aspiration to work thirteen hours a day from 9am-10pm, 7 days a week. However, the team was not working to this yet due to vacancies The Child and Adolescent Mental Health Services on call and mental health crisis teams provided support outside of these hours. Staff told us that children and young people were assessed and discharged much quicker than before the service was implemented. The team had a dedicated consultant who was responsive and took responsibility for solving problems.

The trust had an enhanced care observation risk assessment to determine whether extra staff were required to observe patients with mental health needs. The trust has an observation and engagement policy that has been updated recently.

There was a twice daily nursing safety huddle where staff allocation was facilitated by the nurse in charge. In addition, at every shift change there was an individual handover of each patient by the patient's bedside to ensure each patient was reviewed visually to monitor any signs of deterioration. Key messages were also discussed and included safety alerts, learning from patient safety events, staffing, waiting times compliance, safety checks and safeguarding. Handovers were stored electronically on the trust shared drive.

There were twice daily board rounds at 8am and 4pm.Board rounds bring the multi-disciplinary team together to review patients to get appropriate care and are discharged home when they are ready or admitted to hospital through joint working. We observed a board round and saw that it was in line with RCEM guidelines for handover. For example, the sickest patients were discussed first.

Leaders told us that safety and continuity of care was a priority throughout patient's care journey. Leaders and staff had a strong awareness of the risks to patients across their care journeys including mitigations to these risks. For example, there was a doctor allocated to the non-designated (corridor care) areas where patients were placed. There was a standard operating procedure for care in the non-designated areas (corridor care) for staff to follow. There was a Hospital Full Boarding Protocol (HFBP) on the intranet and all staff were familiar with it.

Staff followed sepsis-six guidelines to manage adults and children with suspected sepsis.

Policies and pathways such as same day emergency care were aligned with other key partners to drive improvements for patient care and treatment. For example, the trust's acute admissions policy had recently been updated to incorporate agreed pathways for patients attending with a letter from a GP.

Assessment findings:

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Patients we spoke with told us they felt safe and that if they had any concerns or issues, they would feel comfortable to tell someone.

Staff we spoke with knew how to identify adults and children at risk of, or suffering, significant harm. Staff understood how to protect children, young people and their families from abuse and the service worked well with other agencies such as police and local authority safeguarding teams, to protect them.

Staff had training on how to recognise and report abuse, and they knew how to apply it. Data provided to us by the trust showed that compliance with all safeguarding training modules exceeded the trust target of 85%.

We observed the triage of a patient attending with injuries related to a mental health need. The patient was treated with kindness, compassion and dignity. The patient was informed of the plan and consented to treatment. Safeguarding concerns were highlighted during the triage process and the nursing staff demonstrated good understanding of the need for safeguarding referrals.

Staff had access to safeguarding policies, which referenced appropriate legislation and best practice guidance. We saw appropriate flags (identifiers) were applied to the electronic patient record to identify patients who were at risk. Safeguarding information was displayed throughout the department.

Staff told us they were confident in raising safeguarding concerns and the process for referrals on electronic patient record system and was easy to complete. Staff were able to tell us when they recently completed referrals. Staff told us there were safeguarding link nurses within the department who provided support and advice when needed.

The service shared concerns quickly and appropriately. For example, the safeguarding team could also send messages about high-risk patients using the electronic patient record system remotely prompting staff to complete referrals if needed.

Staff told us that Deprivation of Liberty Safeguards (DoLS) were not used within the ED, where applicable doctors completed Mental Capacity Assessments (MCA) for best interest’s restrictions.

The trust had delivered a new training course on the MCA and DoLS staff told us that they found the training really helpful.

The department had effective processes and tools for assessing patients when they first presented to the department and monitored patients for signs of deterioration when they remained in the department for extended periods of time. Patients we spoke with told us their wait for triage had been timely. Patients were triaged by trained triage nurses and demonstrated how they used the National Early Warning Score 2 (NEWS2) tool for adults and Paediatric Early Warning Score (PEWS) for children. This enabled staff to identify deteriorating patients quickly and escalate them appropriately. Staff knew how to escalate and monitor patients identified as deteriorating.

The department used electronic screens with real time patient information to monitor the acuity and activity within the department. NEWS2 scores were displayed for each patient and if the score had gone up or down.

Most patients told us that they were informed of why they were being moved between areas in the department and waiting times had been communicated.

Leaders and staff could articulate what risk assessments they used to keep patients safe. Security staff were trained in least restrictive restraint. Data provided by the trust showed that 100% of security staff had completed the initial 3-day training course and 95% of staff had completed refresher training. Feedback from staff was mixed in relation to the availability of security staff but all said they were supportive. Restrictive restraint was only used as a last resort and was monitored by leaders.

There was a corridor standard operating policy which set out the mandatory actions such as minimum staff to patient ratios. Specialist trolleys provided improved protection for patients from pressure skin damage, recognising patients remained in the department longer.

Patients told us they felt safe and supported whilst they were in the ED. They could approach staff if they felt their health was deteriorating and they were confident staff would respond to their concerns.

The trust recognised friends, and family could often see a patient’s deterioration before anyone else does. Therefore, trust had a programme which enabled friends, relatives and patients themselves to make a direct referral to the critical care outreach team if they felt the clinical condition of an adult or child in-patient was actively deteriorating. We saw there was posters and written information informing all patients and visitors of the programme.

Staff we spoke with described the processes to assess and identify patients at risk and how they assessed and documented mental capacity. Alerts on the electronic patient record enabled staff to be aware of specific risks. For example, if a patient was assessed as having a high risk of falls or were living with dementia. Staff had a person-centred approach and involved patients, where possible when completing risk assessments.

The trust had an enhanced care observation risk assessment to determine whether extra staff were required to observe patients with mental health needs. Staff attended a thorough shift handover where risks were communicated.

Partners, such as psychiatric liaison reported they worked well with department staff. Several members of staff commented on the positive culture and working cohesively to ensure the patient was kept at the centre.

There were Safety Standards for Invasive Procedures using the national Safety Standards for Invasive Procedures. There were effective mechanisms to ensure these were reviewed and updated. For example, following a Never Event these were reviewed and updated.

The equipment and facilities, in the main, supported the delivery of safe care. Although patients experienced long waits in waiting rooms and non-designated areas (corridor care), patients told us they were well looked after by staff. There was a separate area for children and their families which was safe and secure and there were toys to keep children occupied. Patients were seen quickly and checked on regularly.

Computers were widely available throughout the department which meant that staff did not have to wait to access them. However, we observed several unlocked and unattended computers displaying confidential patient information on the first day of the assessment. We raised our concerns with the leadership team, on day two of the assessment we observed that all unattended computers were locked to maintain confidentiality.

There was a mental health assessment room which had Psychiatric Liaison Accreditation Network (PLAN) accreditation. However, the doors were broken. The trust had plans to replace these in the next couple of weeks. In the meantime, the service had risk assessed that the room should only be used when members of staff were observing patients, unless patients had been assessed as low risk.

Staff had access to all the equipment they needed and guidance or instructions for using it. There was additional equipment available if required during busy periods. We saw environmental risks assessments were completed.

Planned preventive maintenance and electrical appliance tests were completed and recorded centrally. All electrical equipment we checked had undergone electrical safety checks within the last 12 months. The department's fire safety equipment and emergency systems such as call bells, were tested and maintained appropriately. Fire exits were not blocked, evacuation routes were signposted.

The department had a modern resuscitation area which had capacity for 8 patients, including to treat children and late-stage pregnant women. Each bay was large enough to easily allow for a multi-professional team to care for and treat the patient and have access to a vast range of equipment and facilities.

Equipment, facilities, and technology supported the delivery of safe care. Each treatment area had a standardised equipment. Standardisation of equipment aims to reduce the risk of harm to patients because staff who work between these areas will have greater familiarity with a smaller number of devices, thereby reducing the risk of error.

Staff had good oversight of the department and patients were kept safe while waiting to be seen or receive treatment. There were nurses and a doctor assigned to have oversight and visibility in non-designated areas (corridor care) and the waiting room.

The service had enough staff to keep patients safe and the staff matched the planned numbers on the day. Skill mix was reviewed regularly, and 24-hour consultant cover was available. This exceeded national guidance. Leaders understood the hot spots in the department which demonstrated that a further five consultants were required. The service used minimal (1%) locum doctors. The children's department was covered with doctors and nurses with the appropriate paediatric competencies.

Staffing was flexed to meet the needs of the patients attending the department For example, additional consultants and nurses were rostered on Monday's and Tuesday's, as these were busier days, an additional consultant was present at lunchtime for lunch coverage.

There were robust and safe recruitment practices to make sure that all staff, including agency staff and volunteers, were suitably experienced, competent, and able to carry out their role. There was a suite of policies relating to safe recruitment and all new starters received a comprehensive induction.

The service used bank staff when necessary and regular agency staff, and ensured they were familiar with local systems and processes. Data provided by the trust showed between November 2024 and January 2025, 3% of all shifts were filled by agency staff and 22% of all shifts were filled by bank staff.

Data provided to us by the trust showed that between November 2024 and January 2025 the unfilled shift rated for nursing staff and health care assistants was 6% and less than 1% for doctors.

Leaders told us that there was really good team culture within the department, that across the professions there was good training opportunities and multiprofessional relationships. We were told there was a culture of supporting staff to develop and progress. The latest vacancy rates supplied by the trust showed a vacancy rate of 17% for registered staff which was above the trust target of 8% and 6% for unregistered staff (below the trust target). The most recent data provided to us by the trust showed a staff sickness rate of 4% for nursing staff which was slightly higher than the trust target of 3.3% and 2% for medical staff.

During the assessment, the department was busy with more patients being cared for than the department was built for. This put inevitable pressure on staff. However, staff said they felt able to respond to increasing demand as staff from other areas in the hospital came to support. We observed theatre staff, practice development nurses and doctors from other areas supporting patients. There was a good degree of support and mutual respect among staff working in the department. We observed effective and cohesive teamwork. There was a culture of just "one team" and shared responsibility.

Data provided to us by the trust showed that 87% of eligible doctors had up to date Advanced Life Support training, 95% of eligible doctors had up to date Advanced Paediatric Life Support Training and 100% of eligible doctors had up to date Advanced Paediatric Trauma Life Support Training. The trust confirmed that the doctors who were non-compliant with training had training booked.

Staff received mandatory training appropriate and relevant to their role. Overall compliance for adult nursing staff was 94% ,99% for staff working in the CED and 87% for medical staff. All exceeded the trust target of 85%.

The service had a process for carrying out effective appraisals, 87% of nursing staff had received an appraisal and 90% of medical staff had received an appraisal. Both were better than the trust target of 85%.

Medical staff were supported by named supervisors. Resident doctors had protected time for teaching. Feedback from resident doctors was positive, they felt supported and invested in to develop and gain new skills. Data supplied by the trust showed there was a 5% vacancy rate for Resident doctors.

Staff told us specialised mental health training was available to staff including training as a Mental Health Ambassador. There were 4 mental health leads within the ED: bespoke mental health lead, matron mental health lead, consultant mental health lead, and clinical fellow mental health lead.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff followed infection prevention and control (IPC) guidance. Data provided by the trust showed that 96% of all staff were compliant with IPC training.

During the assessment we observed staff within the service maintain standards of hygiene and cleanliness. Staff washed hands in line with infection control policies and adhered to the uniform policy set out within the service. We observed staff complied with `bare arms below the elbows' policy, in accordance with National Institute for Health and Care Excellence (NICE) guidance. Personal protective equipment and handwashing facilities were readily available.

The service had an effective approach to assessing and managing the risk of infection, which was in line with current relevant national guidance. An IPC policy set out key information for staff to support maintaining infection, prevention and control standards. Hand hygiene, local cleaning and infection prevention and control audits were undertaken by the service. We saw action was taken if areas of non-compliance were identified in audits. For example, in December 2024 and January 2025 hand hygiene audits in the majors area showed that hand hygiene practice was not in line with service policy and national expectation. Therefore, there had been input from the trust IPC teams to improve practice. A trust wide annual infection prevention and control report included information relating to the service included the number of hospital acquired infections.

Domestic staff were visible within the department. We observed both clinical staff and the cleaning staff diligently cleaning equipment and the environment. The floors were clean despite heavy foot traffic and the constant movement of people and equipment.

Clinical areas we saw were clean and had suitable furnishings which were clean and well-maintained. The cleaning schedule set out by the service was followed We saw disposable curtains labelled with the date they were last changed. Cleaning records we saw were up to date and demonstrated all areas and equipment were cleaned regularly. Clinical waste was disposed of safely.

Isolations rooms were designated as part of the resuscitation area of the department and a large tent was available outside of the service for any incidents requiring decontamination.

The service made sure that medicines and treatments were safe and met people's needs, capacities and preferences. They mostly involved people in planning, including when changes happened. We spoke to 1 patient who was discharged from the ED on 5 February 2025 with different medications than they arrived with, they reported that they were not given any counselling on the medications. Counselling patients on changes to medication, can improve patients' understanding of the role medicines play in maintaining their well-being thereby enabling patients to make appropriate decisions regarding their medicines.

Medicines were stored safely and appropriate records kept, including for controlled drugs, medicines requiring refrigeration and emergency medicines. Patient records were flagged on admission to show if they needed time critical medicines or had complex needs. This enabled staff, including the pharmacy team who worked in the ED Monday to Friday, to prioritise patients that should have their medicines checked and administered whilst they waited for further assessment or treatment.

We saw that the prescribing of antibiotics followed trust policy and national guidance Patient Group Directions were available for appropriate staff to use, and the medicines covered by these were reviewed and additions made where this was seen to improve patients' treatment. Some pre-packs of the more commonly required medicines and prescription forms for supply from a community pharmacy were kept in the department to facilitate some discharges.

Medicines were transferred with patients admitted to an inpatient bed, and the record system allowed medicines previously ordered to be sent to where the patient now was.

Staff we spoke with demonstrated how they had learned from incidents and improved practice. They spoke of the open culture of reporting errors and concerns. We saw that patient safety alerts had been acted on and information disseminated to the teams. Audits, including for medicines storage and missed doses, led to some improvement actions