Wexham 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

We assessed a total of 8 quality statements from this key question.

Our rating for this key question stayed the same. We rated it as good.

We found the service had a positive learning safety culture based on openness and honestly, where events were investigated, and learning was shared and embedded to promote good practice and continuous improvement. There were established safe systems of care in which safety was monitored and assured. There were processes to manage patient risk. Staff assessed risks to patients, acted on them and kept good care records. Staff had effective and embedded understanding in how to protect patients from abuse. The environment was safe and well maintained, equipment, facilities and technology supported the delivery of safe care. The service practiced high standards of infection prevention and control. There were enough qualified, skilled and experienced people, who received effective support, supervision and development. They worked together effectively to provide safe care. Medicine management was safe and met people’s needs.

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.

There was a strong culture of safety and learning throughout the service. The department had created an environment that prioritised and encouraged both individual and organisational learning, it was an embedded practice.

The service had processes to collect data from various sources, including performance and outcome data, and feedback from patients and staff. There were policies, procedures and meetings to interrogate and investigate data. The results were used to actively learn from findings and drive continuous improvement, and implement changes in practices to improve safety, care and outcomes for patients.

The service understood the need to re-investigate and evaluate the impact of any new practice. This involved assessing whether the changes were having a positive impact and whether the new practices were being consistently followed by the team.

The service had a culture that prioritised openness and honesty when things went wrong. They knew this was crucial for learning and improving performance. Staff were encouraged to raise concerns and report incidents and near misses in line with trust policy. There was a no-blame culture and staff said they felt confident in reporting incidents. Staff understood duty of candour. When something went wrong, people received a sincere and timely apology and were told about any actions being taken to prevent the same happening again. We reviewed learning responses which showed duty of candour was completed appropriately.

The trust had implemented the April 2024 NHS England’s Patient Safety Incident Response Framework (PSIRF), which had changed how incidents were investigated and concentrated on the learning and improvement of patient safety.

The service had reported no never events in the emergency department (ED) in the last 12 months. A never event is a serious incident which is wholly preventable, where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers.

Between March 2024 and February 2025, the ED reported 1842 incidents. Of these, 75% were rated as no harm, 21% rated at low harm (minimal harm – patient required extra observation or minor treatment) and 4% rated as moderate harm (short term harm - patient required further treatment, or procedure), there were 3 incidents of severe harm (permanent or long-term harm) and no deaths. The incidents were categorised to see if there were any themes or trends, the top 3 themes were, behaviour and security (34%), issues with onward care (26%) and pressure ulcer damage (18%).

The service had used this data to see what measures were needed to mitigate or stop reoccurrence of incidents. For example, matrons had reviewed all the incidents of violence and aggression towards staff and other patients, looked to see the underlying factors, such as overcrowding, day and time the incident occurred. This evidence had resulted in security staff wearing body worn cameras. They were used to enhance safety and accountability by acting as a deterrent to violence and aggression, providing a record of incidents, and aid in the de-escalation of potentially volatile situations. Security presence had been increased at the times where the investigation had shown increased aggression, for example at nights and weekends. The service were continuing to monitor to see if these measures were adequate and had reduced aggression seen in the department. Findings were to be presented at the clinical governance meeting and further actions would be agreed on if required.

Between March 2024 and February 2025 there had been 2 incidents recorded as needing patient safety incident investigations. The trust had transitioned to the NHS England’s Patient Safety Incident Response Framework (PSIRF) in April 2024 and used this approach to respond to patient safety incidents. This meant the service focused on learning and improvement rather than solely on investigation and reporting.

We reviewed learning responses resulting from patient safety events which demonstrated a good level of family and patient involvement in the investigation. 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.

The service used complaint data to improve services. Between March 2024 and February 2025, there was a total of 116 formal complaints received. The main themes being clinical treatment (49%), values and behaviours of staff (15%) and communication (10%).

The trust had embedded practices to ensure all complaints were reviewed, reported and responded to according to the trust’s complaint policy. Complaints relating to the emergency department, whether individual or themes, were discussed at the clinical governance meeting. Any learning or action required was identified and completed.

For example, a presentation was delivered to staff on the importance of effective communication with patients and their families. This was to give staff the tools to have difficult conversations, such as end of life, to reduce complaints relating to poor communications. The department had trained volunteers in certain roles, such as hydration rounds for patients, to support both patients and staff during very busy times in ED, this was in response to complaints relating to long waits in the department.

The service analysed positive feedback and compliments as a way to highlight good care and to acknowledge when staff had performed well. Between March 2024 and February 2025 the department had received 40 formal compliments. For example, a patient who attended the department was triaged immediately but was categorised as non-urgent. It was explained there would be at least a 4 hour wait to see the clinician however certain tests would be carried out during that wait. When the clinician saw the patient, all test results were available, leading to a clear diagnosis, plan, and a sense of reassurance, resulting in a positive patient experience despite the wait. This highlighted how the training in communication and the effective planning of care had provided a positive patient experience and outcome.

The service used many ways to share learning with the teams and wider trust. These included safety alerts encrypted electronic messages, safety huddles, handovers, safety snippets, patient safety briefing forums, face to face training, patient stories and posters on the back of staff toilet doors. Staff could share examples of learning and changes made to improve outcomes and patient experience. This included how information gathered at triage was displayed on the electronic patient record meaning all staff had access to the information immediately. This was due to a near miss when a patient was prescribed penicillin even though the patient had informed staff at triage they were allergic to it.

There was a central log of National Patient safety Alerts, which were shared with staff and actioned as appropriate.

The department held mortality and morbidity meetings to discuss patient deaths or adverse incidents affecting patients. This was essential for identifying potential areas for improvement in care delivery as well as learning from cases to enhance patient safety. These meetings gave an opportunity for the clinical team to review deaths as part of their professional learning and reflective practice in a safe space. Talking through patient case studies was seen as a way to improve quality of care given to patients and their families in the department.

Patients either arrived at the emergency department (ED) by ambulance or by self-presenting to the department. Ambulance crews transferred the patients’ care to the ED team, involving a formal handover of information about the patient’s condition, treatment and history. Self-presenting patients would be initially assessed by the nurse navigator at the front door to determine the most appropriate care pathway within the hospital and wider system.

The service used an electronic patient administration system. This system was used to register patients, monitor their movement through the department and wider hospital if admitted. The computer system had the facility to add electronic alerts to make staff aware of specific needs of patients such as those living with a learning disability or dementia.

Patients would then be assessed and a decision made about the patient’s treatment depending on severity of their condition. A range of clinical pathways existed. These ensured patients presenting with specific conditions could expect to receive standardised care and treatment aligned to best practice recommendations. Patients would be risk assessed on arrival to the ED and at specific timeframes depending on their clinical pathway to assess for deterioration or improvement of their condition. The department used audits to ensure risk assessments were being carried out and recorded appropriately and in a timely way. Data evidenced assessments were completed correctly the majority of time. For example, the emergency severity index (ESI), a tool used at triage to help determine the urgency of a patient’s condition and hence the timeliness of the treatment needed, was correctly assigned 92% of the time between May to November 2024, and for the same time period, 97% of patients had their pain assessed on initial assessment. However, skin integrity checks were sometimes delayed for patients being cared for in the corridors as they would need to be taken to an area of privacy for these assessments to be carried out to maintain their dignity. Finding a space and coordinating staff to complete these assessments was difficult when the department was busy. This meant there was a potential delay in recognising, managing and preventing deep tissue injury.

Due to longer stays in the department because of increased capacity, the service completed care rounds when the patient had been in the department 6 hours and every 6 hours thereafter. This was to ensure patients were being cared for appropriately, for example on an appropriate trolley and their food and hydration needs were being met.

The service used staff handovers to transfer the responsibility for a patient’s care from one healthcare professional to another. We observed staff handovers, they were structured and focused on the patient’s needs and were in line with the Royal College of Emergency Medicine (RCEM) guidelines for handovers. For example, the sickest patients were discussed first. They were completed in areas free from distraction and where patient details could not be overheard by other patients or visitors.

Staff in the ED and wider hospital were working together to reach the Department of Health’s standard 4-hour target of patients being admitted, transferred or discharged within four hours. Figures showed the service was reaching this target 69% of the time over the last six months.

Patients who were discharged directly from ED would receive a summary of their care, outlining the ED visit’s purpose, findings and any necessary follow up or treatment recommendations.

We observed patients in ED, due to be admitted to hospital wards for continuation of their care, experiencing delayed transfers to the wards. We were told delays occurred due to lack of bed space on the wards. Patients not moving out of ED beds was contributing to the overcrowding in the ED department, long waits, and patients needed to be cared for in the corridors. ED staff told us they had good relationships with speciality doctors who would come to the ED to review patients. The service followed policies and standard operating procedures to mitigate risk to patients when the department was over-crowded, which we saw in operation during the inspection. The service was also working with the trust and wider health and social care community to look for ways to increase hospital flow and reduce non-urgent patients presenting to ED.

The trust had adult and children safeguarding policies which were in date and reflected current legislation and guidance. These policies provided staff with guidance on how to identify abuse and the processes to follow if they needed to raise a safeguarding concern. The policies covered other elements of safeguarding such as radicalisation and female genital mutilation. Policies included what immediate actions to take to keep people safe, and the procedure to follow if the person lacks capacity. There was a quick reference guide for staff which gave step-by-step details of how to make safeguarding referrals.

Safeguarding was part of the staff induction and mandatory training. Staff had the appropriate level of adult and children safeguarding training allocated for their role. The trust set a target of 85% for completion of safeguarding training. ED staff met trust targets with an overall 92% completion rate. However, when safeguarding mandatory training was broken down by role and safeguarding level, 2 out of the 8 modules were not meeting trust targets. Medical staff were 78% compliant with their adult safeguarding level 3 training and 80% compliant with their children safeguarding level 2 training.If staff haven't completed the required safeguarding training for their role, even if the training level was appropriate, it can lead to potential risks as untrained staff may not recognise warning signs of abuse or neglect, leading to missed opportunities to intervene and protect vulnerable individuals.

Staff we spoke with knew how to recognise and report safeguarding issues and knew who to escalate their safeguarding concerns to. The trust had two designated safeguarding leads who were the point of contact for the team. Members of the trust safeguarding team visited ED regularly to offer support and supervision to the team. The ED had a nominated consultant and the head of nursing, who were responsible for safeguarding.

Information on safeguarding issues was displayed throughout the department. This was visible to patients, visitors and staff. The information displayed included who to contact if abuse was suspected or seen.

All patients under 18 that presented to the ED were checked on the national database for any safeguarding or other concerns. When concerns were identified, this was noted on the patient record for the clinical staff to see. Information about when children had attended the paediatric emergency unit was shared with health professionals and relevant authorities.

Staff knew how to make a multi-agency safeguarding hub referral and demonstrated this during our inspection. The multi-agency safeguarding hub brought together a team of multidisciplinary professionals from partner agencies into the same room to deal with all safeguarding concerns, where someone was concerned about the safety or wellbeing of a child.

Patients self-presenting to the emergency department were assessed on arrival by a senior nurse and directed, depending on their clinical need, to different areas of the department or hospital. In some cases, if their condition was not a life-threatening emergency, they would be directed to other healthcare providers, for example an urgent care centre.

The ambulance service pre-alerted the department if a patient was on route and needed urgent medical care. This was to make sure an appropriate team was waiting for the patient on arrival in the resuscitation area.

The service used the emergency severity index score (ESI), which is a 5-level system that helps determine the urgency of a patient’s condition and allows clinicians to determine who needs immediate attention and who could safely wait. This triage included making sure the sepsis six bundle was promptly started. Our observations and audits carried out by the service showed patients were assessed appropriately, risks highlighted, and care plans put in place in a timely way.

The service used a mental health triage tool to assess and prioritise patients with suspected or diagnosed mental health conditions. This was used to determine immediate risks, the level of observation needed to keep the patient safe whilst in the department and the appropriate response required.

The service used the National Early Warning Score (NEWS2) tool, a system for scoring physiological measurements in adults, to clinically observe and identify those at risk of deterioration. Paediatric patients were monitored using the paediatric early warning score (PEWS) during their stay in the department. All records we reviewed had accurately calculated NEWS2 or PEWS scores and where required, appropriate action was taken if the score was raised. The department completed monthly NEWS2 and PEWS audits for completeness, accuracy and appropriate action taken. From January to February 2025 audit results showed NEWS2 were recorded appropriately and generally repeated where indicated, with sets of observations being carried out in line with NEWS2/PEWS protocol. Patients were reviewed by the appropriate clinical staff based on their score and patients with a raised NEWS2/PEWS score were seen quickly by a clinician.

The current ED status for all patients was displayed in the main hub and on each of the computer on wheels (CoWs) used out in the department when staff were logged on. This provided real-time and live tracking of all patients in the department. This included an up-to-date display of the ED key metrics such as patient’s time in the department, the average time to triage, longest patient stay and their NEWS2/PEWS score. This gave the whole team the complete picture of what was happening in their department, the current status of patients and their severity of illness.

Due to an increase in the number of people presenting to ED, the service was having to implement caring for patients in the corridors of the department. The service had an ambulance line standard operating procedure (SOP) which gave clear guidance on how to ensure patient safety and protect patients’ dignity and privacy, whilst being cared for in a corridor. The service audited against these guidelines to highlight what they were doing well, where there were concerns and the actions taken to address the concerns. Although corridor care is not best practice, the measures the service had in place ensured patient safety risks were mitigated, and patients were still receiving good care and treatment.

All children and young people under 18 had an electronic child protection risk assessment completed. The electronic patient record system would flag any patients known to be at risk.

The department had implemented ED 6 hourly care rounds to enhance patient safety and clinical performance. Senior staff would check to ensure basic elements of care were addressed, such as skin integrity, food and drink given and observations, and potential issues identified and addressed promptly. Post-inspection we asked the trust for care rounds audits results. For January and February 2025 6 hour care rounds were not completed 22% of the time.

During the inspection we attended and discussed staff handovers. We observed risks to patients were reviewed. This meant staff were aware of patient’s individual risks and the care plans or treatment required.

There were policies and procedures for staff to follow in relation to extra observation, supervision, restraint and, if needed, sedation. A range of clinical pathways existed. These ensured patients presenting with specific conditions could expect to receive standardised care and treatment aligned to best practice recommendations.

The trust operated a service called Call 4 Concern. This gave patients, families and staff the ability to directly refer to the Critical Care Outreach team and get an independent medical review if they felt their concerns about a patient’s care was not being adequately addressed. We saw posters and written information informing patients and visitors of this service.

There was limited access to certain areas of emergency department (ED) with access only gained by swipe card or intercom which created a secure environment.

The department was split up into areas of care, patients would be allocated to each area depending on their severity of condition: resuscitation unit, rapid assessment and treatment (RAT), major and minor injuries. Areas were well-maintained and monitored to ensure safe upkeep.

The rapid assessment and treatment area (RAT) and resuscitation unit were either side of the area where ambulances came in, which helped ambulance staff to transfer ill and seriously ill patients to the care of the emergency team quickly. The resuscitation unit had 7 adult bays and one paediatric bay. The bays were large and spacious, allowing plenty of room for a full resuscitation team as well as a vast range of emergency equipment.

The major injuries area had 30 bed bays. The layout and equipment was standardised in each area making it easier for staff, who worked between areas, to know the location of equipment and how it worked. This helped staff improve patient safety, reduce errors and enhance efficiency for patients.

Due to patient numbers outstripping capacity in the department, patients were being treated in non-designated areas, such as corridors. The service followed a standard operating procedure when this occurred to ensure patient safety, such as additional staff and equipment, and appropriateness of the patient to be cared for in this environment. There were emergency call bells in the corridor and staff working in the corridor wore radio headsets which provided a constant communication link with clinical colleagues and the nurse in charge.

There was a dedicated mental health assessment room in ED, which met quality standards and provided a safe environment for patients and staff. There were no ligature points, furniture could not be lifted or moved, and the room had an alarm system with two doors that opened both ways.

The department had a separate viewing room for families to see their relative’s body if they had passed away. The Royal College of Emergency Medicine: End of life care for adults in the emergency department 2015 recommends this as good practice.

Self-presenting patients entered the ED through a dedicated entrance with clear signage. There was a large spacious waiting room and off this area were the triage rooms and the entrance to the minor injuries unit. The layout of the main waiting area meant reception staff had limited line-of-sight of patients waiting in the area. Although patients were initially assessed on arrival, at times due to high volumes of people self-presenting, there could be long waits for further treatment. The service had measures they implemented if long waits occurred to ensure deteriorating patients were spotted and escalation occurred. This included, having a designated member of staff in the waiting area monitoring the wellness of patients.

Diagnostic imaging facilities were co-located in the department which allowed for diagnostic procedures to be completed quickly if patients were waiting for a specialist review.

The paediatric emergency department was co-located but physically separate from the main ED. It could only be accessed by authorised persons via a swipe card or the intercom. There was a separate paediatric waiting area inside the department. This area was bright and colourfully decorated. There was a play area and a television showing cartoons for younger children. The waiting room had a one-way window, which meant staff in the paediatric department could see into the waiting room and a deteriorating patient or disturbance would not go unnoticed. However, children and their families could not see into the actual department. There was no dedicated paediatric mental health room in the department, and child and adolescent mental health services, when needed, would use the adult mental health room. However, the paediatric ED had a quiet room, which if assessed as safe, would be used by some children.

The emergency department made sure staff handovers were conducted in areas where they could not be overheard ensuring patient confidentiality was not breached.

Staff carried out daily safety checks of specialist equipment. Resuscitation equipment, including the infant resuscitaire, was readily available and was routinely checked to ensure it was ready for use. We reviewed records which confirmed checks occurred daily.

Point of care testing equipment in the department included glucose meters, urine testing sticks and a blood gas machine. Equipment and consumables were stored appropriately. There was evidence equipment was serviced and electrical safety checks completed. ED staff also completed their own monthly checks of equipment to ensure all kit was fit for purpose. Consumables we checked were in date.

Adjacent to the emergency department was a purpose-built decontamination unit, which allowed for the safe removal or neutralisation of hazardous substances from individuals who have been exposed.

There were systems which ensured that clinical waste, including sharps, was appropriately segregated and disposed of. During our inspection we observed sharps bins were correctly assembled and labelled in line with national guidelines.

There were appropriate staffing levels and skill mix to make sure people received consistently safe, good quality care that met their needs. Staffing levels were reviewed yearly with the last review November 2024.

Managers calculated and reviewed the number and grade of staff needed for each shift according to best practice and department need. When the number of patients receiving corridor care reached a certain level, senior staff followed procedures to increase staffing levels to keep people safe. Staffing levels for corridor care being 1 registered nurse to every 4 patients receiving corridor care.

Currently the department had approximately 10% vacancy rates for qualified nurses and administration staff and 23% vacancy rate for medical staff. The vacancies were mainly tier 2-3 doctors. This was above the trust's vacancy target rate of 8%. We were told recruitment was on-going to reduce the vacancy rate.

The department used bank and regular agency staff to cover gaps in the rota to make sure staffing levels kept patients safe. They ensured they were suitably experienced, competent, and able to carry out their role. Sickness levels in the department were low and below the 3% trust target for sickness.

The department always had a tier 4 clinician on the ED floor as required by the Royal College of Emergency Medicine (RCEM), and there was consultant cover between 8am and 10:45pm seven days a week which did not adhere to the RCEM recommendations of 16 hours per day. Outside of these hours a consultant was on-call and could be contacted. We were told by the consultant lead for ED there were plans to increase consultant cover to 16 hours per day but there was no time frame specified.

The paediatric ED had cover by a paediatric emergency medicine consultant 7 days a week but the times they were in the department varied. The unit employed registered children's nurses, with always a minimum of two on shift with trauma and emergency training, which met the Royal College of Paediatrics and Child Health recommendations. The department had their own designated play specialist, but they only worked two days a week. At other times, if available, the service could call on the services of the play specialist who worked on the children and young people's wards.

Emergency nurse practitioners (ENPs) were used in the department. ENPs were qualified to assess, diagnose, treat and discharge patients with certain injuries without having to refer to a doctor.

Due to the increase in patients presenting at the ED with mental health concerns the service had employed two dedicated mental health trained nurses and had sourced training from the local mental health NHS trust for their staff to gain understanding and be able to care for these patients appropriately whilst in the department.

The emergency department employed security guards through a third party, however this was not 24-hours a day, seven days a week but mainly only at weekends. The service could call on the wider hospital security team if incidents occurred at other times, and they would send someone to the department if available. However, incidents of violence and aggression towards staff was increasing and staff, leaders were concerned for the safety of the team, and the department was requiring more assistance from the police service to deal with incidences. Patient violence and aggression towards staff had been put on the department risk register and ED leaders were raising their concerns regarding staff safety with the trust's executive team.

Staff received mandatory training appropriate and relevant to their role. Overall compliance for nursing staff was 96% and 87% for medical staff. However, 7 out of the 20 modules required by the medical staff were under the 85% trust target, with risk and patient safety level 2 training being the lowest at 62%. The risk and patient safety level 2 training was a national module which had been introduced in 2025. The service had a target date to reach training compliance by October 2025.

The department had three dedicated practice development nurses and a nurse consultant to provide support and education to clinical staff and to improve their professional practice. Staff were extremely complimentary about having these roles in the team and how they had made a positive difference to performance. There was a structured development programme for all staff that included unit and role specific induction programmes, supernumerary periods for new nurses to the team, competency frameworks and career development matrixes.

After the initial ED competencies had been completed the department ran additional training for nursing staff which included more specialised training in areas such as plastering techniques, triage training and simulation (SIM) training.

Supervision took place at regular intervals between junior staff and their mentors. This gave the opportunity for individual staff performance to be identified and managed.

The department was committed to providing support and training for junior and trainee medical staff. This included a dedicated teaching and training programme. Feedback from medical staff was positive and they felt supported in their development.

Managers supported staff to progress through regular development meetings and yearly constructive appraisals of their work. Staff had the opportunity to discuss training needs and were supported to develop their skills and knowledge. Staff told us they found the appraisal process useful, and they were encouraged to identify any learning needs they had, and any training they wanted to undertake. Poor or variable performance was identified through the appraisal process, complaints, incidents and feedback. Staff were supported by their managers and the practice educators to improve their practice where indicated. 87% of nursing, healthcare and allied health professionals working in ED had received an appraisal and 93% of medical staff had received an appraisal which was better than the trust target of 85%.

The department had dedicated housekeeping staff who were responsible for cleaning patient and public areas, in accordance with daily and weekly checklists. Cleaning records were up-to-date and demonstrated areas were cleaned regularly and deep cleaned when necessary. Cleaning equipment was stored securely in locked cupboards. This meant unauthorised persons could not access hazardous cleaning materials.

We saw cleaning staff on the unit throughout our inspection and our observations showed a visibly clean, tidy and clutter free clinical environment. Furnishings, such as chairs and flooring were wipeable and easy to clean.

Cleaning audits were completed for the emergency department to make sure cleaning standards did not fall below certain levels.

People were protected as much as possible from the risk of infection. The department had cubicles for isolation in both the adult and paediatric EDs, with some having their own toilet facilities. Signage was used to advise staff and visitors not to enter these areas without appropriate protective clothing. The resuscitation area used a ventilation system with a high air change rate to help reduce the risk of airborne infections by diluting and removing infectious particles in the air quickly. Patient's infectious status was checked when they arrived at the department either by the navigation nurse at the front door or when patients were being handed over by the ambulance crews.

The department had an infection prevention and control (IPC) lead and linked into the trust's IPC team who would give advice, educate staff, conduct audits, monitor infections and collaborate with other stakeholders and agencies to ensure a safe environment.

Senior ED staff also conducted their own weekly environmental workarounds. This highlighted any concerns quickly and made sure ED areas were clean and clutter free.

Staff were required to complete IPC training during their induction and then annually at the level appropriate to their role as part of their mandatory training. Staff were up to date with IPC training with records showing 97% compliance for the ED.

Staff followed infection, prevention and control (IPC) principles, the trust's policies and national best practice guidelines, including the use of personal protective equipment (PPE). Staff had access to PPE and wore disposable gloves when required. Staff had the facilities needed to effectively wash their hands to help prevent avoidable health acquired infections. The department was equipped with adequate hand-washing facilities and hand sanitiser gel was available throughout the department for both staff and service users.

We observed staff who had interactions with patients followed the trusts policy and national best practice guidelines, staff maintained arms bare below the elbows, washed or gelled hands between each patient contact, used personal protective equipment such as gloves, aprons and protective face masks when needed and kept clinical equipment clean.

The department's compliance with infection control practices was audited. The audit programme was used to maintain and improve standards and to help prevent the spread of infection. Post inspection we reviewed IPC audit data which evidenced strong compliance to IPC standards. Where standards did fall short, action plans with timeframes and who was responsible for improvement were documented and acted upon.

Medicines were stored safely and appropriate records were kept, including medicines requiring refrigeration. The emergency department (ED) used an electronic medicine storage and record-keeping system. This helped with making the process of ordering and managing the stock of medicines more efficient. However, the paper-based records for the patient’s own controlled drugs were not always kept as per the trust policy and national guidance.

Emergency medicines and equipment were checked regularly by staff members using an electronic system that used QR codes. However, the staff had to use their personal devices, as the Trust’s handheld devices did not have the functionality to make use of the QR codes. The Trust had identified this and was looking into resolving this.

Patient records were flagged on admission to show if they needed time-critical medicines, high-risk 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. Pharmacy dispensing staff were available 7 days a week for discharge medication dispensing.

The trust pharmacy department had introduced a new role after a successful pilot. The new role remotely reviewed patients’ GP records to list current prescribed medicines, this helped enhance medicines reconciliation.

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.

A limited stock of pre-labelled medicines was available to be dispensed by the nursing staff to help with timely discharges. NHS 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.

There was a process in place to report incidents and errors. The 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.

The pharmacy team was involved in delivering medicines training to staff.

We saw that medicine safety alerts had been acted on and information disseminated to the teams. Audits, including for medicines storage and missed doses, gave assurance and led to some improvement actions.