New Royal Liverpool University

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

At our last assessment we rated this key question requires improvement. At this assessment the rating remains requires improvement.

Staff managed medicines well and involved people in planning any changes. However, trust policy was not always followed when administering rapid tranquilisation medicines and some medicines were not always stored correctly. We fed this back to leaders at the time of inspection and assurance was provided that action was taken to address these areas. The division experienced higher levels of hospital acquired infections.

The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly and people were protected and kept safe. Staff understood and managed risks. The facilities had been adapted to meet the needs of people using them, they were clean, well maintained and any risks were reduced or mitigated. There were enough staff with the right skills, qualifications, and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Peoples experience

We spoke with and provided questionnaires to 23 service users and relatives. Almost all the respondents were aware of how to raise concerns and felt confident they would be treated with compassion and understanding if they did so.

Feedback from staff and leaders

Staff reported a positive learning culture based on patient safety events. They were confident to report incidents and raise concerns. Staff said actions were taken in a timely manner.

Managers informed us they shared lessons learned from incidents or complaints through daily safety huddles and handovers and regular meetings, emails and newsletters. Staff provided multiple examples of when improvements had been made following learning from patient safety events.

There was evidence that changes had been made because of feedback. There had been 1,258 falls between September 2023-24 across the division. A quality improvement project was established and additional falls training for staff arranged. Falls alarms and equipment were used and staff linked in with the falls co-ordinators. Staff told us they had seen a reduction in falls since the implementation of these changes. There was a falls prevention nurse who was very present on the wards and a monthly falls strategy meeting where themes and actions were discussed. Staff and leaders understood the duty of candour and gave patients and families a full explanation and apology when things went wrong. The duty of candour requires registered providers to act in an open and transparent way with people receiving care or treatment from them.

Managers were able to share patient safety themes and trends relating to their ward and also within their medicine division. They told us that actions from safety alerts were implemented and monitored.

This trust had recently been awarded National Preceptorship Interim Quality Mark for its comprehensive preceptorship programme.

Processes

The division had clear processes for staff to follow for reporting incidents. There were effective systems to review and investigate incidents. Risks were not overlooked or ignored. Managers and leaders discussed recent incidents at weekly safety meetings. They would escalate any incident that met the criteria for external reporting or may require a learning response. Any immediate learning was shared with staff and embedded into daily practice. Incidents were not closed off until all actions had been completed. Themes and trends of incidents, safety actions or learning would be escalated and discussed at a monthly trust wide shared learning and improvement forum to promote a safe culture. For example, the forum had most recently reviewed incidents associated with nutrition and hydration.

The service reviewed incident data regularly, from April 2024 to the end of September 2024, 5,325 incidents were reported in relation to medical care. The most frequent type of incident reported related to medication incidents, pressure ulcers and falls. The service reported 5 never events in the last 12 months. Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event. We saw that actions were taken following the reported never events and changes to practice made. The never events reported did not have repeated themes emerging.

We reviewed incident data for the service and found most cases were handled promptly after they had been reported.

The service reviewed incidents and completed patient safety incident investigations when required. We reviewed the last 5 incident reports completed which were detailed and had suitable improvement actions included.

The service had process in place which ensured mortality reviews were completed when a service user died.

The wards/areas we visited had noticeboards which provided examples of learning from incidents. Displays also provided reminders to staff to reduce the risk of incidents such as wearing 'medicine round in progress' tabards and speech and language therapy (SALT) assessment and referrals.

Peoples Experience

Patients being treated on the days we visited told us they felt safe and informed about their care. We saw how patients' information was shared with relevant health professions and that records were updated by multidisciplinary team members. Systems were in place to ensure sharing of patient information between relevant health professionals

Feedback from staff and leaders

There were systems and processes in place to ensure continuity of care, including when people moved between services. Staff and leaders confirmed safety and continuity of care was a priority for patients with a collaborative approach to safety. We saw positive examples of patient flow management throughout the division of medicine. Patients requiring specific specialist treatment could be directly admitted to wards to ensure treatment was promptly started, for example those patients with a cardiology condition were directly admitted to the ward.

However, leaders acknowledged patients spent longer than they should on the medical assessment unit (MAU) after a decision to admit had been made and some patients experienced discharge delays from ward areas due to waiting for medicines or transport. This was because of the number of patients requiring admission and fewer patients being discharged due to complex care needs and availability of services to support them on discharge.

Additional temporary escalation areas on wards had been modified for those patients who were admitted to the ward whilst they waited for a single room to become available. Leaders explained some of these areas were being redesigned to ensure patients had access to a nearby toilet, privacy, oxygen and call bells.

Leaders and managers told us they had worked hard to make improvements to systems of care for patients. They had implemented a new document baseline assessment to assess the care needs and risks for patients being admitted to the medical wards. This ensured all health needs and risks were assessed as well as patients medical, physical and communication needs based on what was required for that patient. Completion of the documentation including all risk assessments and follow up actions were monitored by managers on a monthly basis and reported in senior meetings. Spot checks were also carried out and discussed at team meetings.

Feedback from Partners

Partners and stakeholders provided positive examples of collaborative work with staff and supported patient admissions, and discharges. Community staff attended daily bed meetings on the medical admission unit. There was a strong combined emphasis to make sure patients were discharged to the right place especially for those with complex needs. Partners worked together with staff to prevent patients being readmitted into hospital unnecessarily.

Processes

The division had clear processes for effective communication and maintaining oversight of patient care and treatment from admission to discharge.

There was a multidisciplinary approach to board and ward rounds, safety huddles and multidisciplinary team meetings. Three daily bed meetings were held in the medical assessment unit (MAU). Attendance at these included operational and leadership staff.

Staff who worked in the bed flow team operated 24 hours every day to improve patient flow through the medicine division. A continuous flow model was in operation and patients were tracked throughout the division, including whilst waiting in additional spaces on a ward.

The division operated a streamlined service to avoid unnecessary admissions to the emergency department for cardiology and respiratory patients who met the ward admission criteria. They would be reviewed on the ward by a consultant and onward care arranged. The frailty same day emergency care (SDEC) would admit patients directly from home.

Patient records were completed consistently. However, when specific pathways were deemed no longer appropriate for patients the supporting documentation was not always stopped. This meant that some patient observation charts and records appeared incomplete.

The division demonstrated positive and effective audit processes for patient safety and completed daily, weekly and monthly assurance audits.

Staff referred to a dashboard to track patients through the division and identify those ready for discharge and those waiting to be admitted.

Feedback from staff and leaders

Staff knew how to identify adults and children at risk of, or suffering, significant harm and worked with other agencies to protect them. They knew how to make safeguarding referrals and who they could contact if they had concerns.

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Senior staff demonstrated a good understanding of the safeguarding processes including linking in with medical social workers. Staff mostly had a good understanding of deprivation of liberty safeguarding practices and when restraint would and would not be used. However, staff did not always follow trust policy when administering medicines to support people's behaviour.

Staff were confident in explaining that service users with medical emergencies in eating disorders (MEED) would be referred to the safeguarding team, a dietician and the mental health liaison service.

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Processes

There were effective systems, processes and practices to make sure people were protected from abuse and neglect.

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Safeguarding referrals had been completed appropriately.

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Staff received safeguarding training specific for their role on how to recognise and report abuse. The training compliance rates for levels 1, 2 and 3 safeguarding training for adults and children were above the trust target for nurses (96% and 94%). However, medical staff were just below target (85% and 83%).

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There were clear processes to guide staff when making a Deprivation of Liberty Safeguards (DoLS) when it is in the best interest of the person.

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DoLS referrals reviewed had been completed appropriately for patients who had fluctuating capacity with a clear explanations documented.

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Due to the move to the new building and ward layouts one ward identified an increase in patients who lacked capacity absconding from the ward as the doors out could be opened by pressing the button. This had been escalated as a divisional risk and an assessment undertaken to prevent it happening. As a result, those patients who presented a risk of absconding were not routinely placed in the first zone on the ward.

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Staff were committed to improving their knowledge of the Mental Capacity Act by undertaking further training and utilising the knowledge of the safeguarding link team for a greater understanding of patients who lacked capacity. A dedicated safeguarding information board was available to all staff and learning regularly discussed at ward meetings.

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Peoples experience

Patients we spoke who had been risk assessed reported that staff were fully aware of their risk factors including diabetes, risk of falls, modified diet and mobility. Patients gave positive examples of how staff “were always there” for them, “helped” and “they (staff) never leave my side” when using frame to aid walking.

Patients waiting for a bed on wards received up to date and clear information and reported the communication to be "great".

Feedback from staff and leaders

Staff were able to describe the process for escalation of a deteriorating patient in line with trust policy. They felt confident to escalate concerns to managers and medical doctors at safety huddles or board and ward rounds.

Staff understood the importance of recognising the signs of sepsis early and knew how to escalate a patient so they would receive treatment quickly. They followed the latest sepsis guidance.

Staff told us they performed daily enhanced observations to reassess patient risks. This included any new risks following new medication. Intentional rounding was completed every 2 hours for patients at risk of pressure ulcers. Managers were able to demonstrate that patient risk assessments were completed promptly, accurately recorded and regularly reviewed. Falls risk assessments were reviewed at least every 5 days if the patients circumstances did not change in the interim period.

Patient documentation and electronic notices outside patient rooms evidenced patient risk assessment completion such as the requirement of a red tray for those who required assistance with food and drink.

Weekly review of falls took place at managers meetings to identify the circumstances of patient falls and share learning. Managers were able to describe their top risks for their ward and division and clearly articulate the mitigating plans to address each of these risks.

Patients' needs were prioritised and those patients receiving end of life care were reviewed by the pharmacist and the palliative care team first on ward rounds.

There was an effective structured handover process between staff changes which was regularly monitored and assessed for compliance. Audits were undertaken throughout the department to monitor compliance with policies and procedures.

Patients were assessed for risks resulting from falls, pressure area breakdown, absconding, and safeguarding.

Processes

Staff used the nationally recognised national early warning scores (NEWS2) tool to identify deteriorating patients.

The division had appropriate, clear and comprehensive standard operating procedures for the medical emergency team and resuscitation, sepsis and NEWS2.

Training records showed that all eligible staff had completed sepsis training. Adult and basic life support level 1, 2 and 3 training compliance was varied for nursing staff (82 to 100%) but lower for medical staff (51 to 73%).

The division provided emergency measures sepsis audits completed between July 2023 and June 2024. Compliance rates above Advancing Quality (AQ) programme target - blood cultures taken diagnosis (60%), IV fluids given (95%) and care pathway commenced (70%) within a 1 hour of sepsis. NEWS2 recorded within 1 hour of hospital arrival (90%), antibiotics given (60%) and microbiology tests taken (57%) within an hour of sepsis diagnosis and senior review within 2 hours (59%).

Staff proactively followed processes to identify and manage risk for patient safety.

Patient records showed fully completed and timely risk assessments for each patient. These were recorded daily within a short stay or 7 day patient booklet. This included, but not limited to, fluid and food charts, behaviour ABC chart, body map for pressure ulcer and international rounding. Environmental, ward/zone and falls daily check lists were fully completed.

Patient risk factors were discussed at safety huddles, handovers and ward and board rounds to keep patients safe.

The trust had its own internal ward quality assessment programme. Each ward was assessed and given a score. Across the 17 wards in the medical division 6 were graded as red (79% or below) 6 were graded as silver (80-90%) and 5 were graded as gold (90-100%). For individual ward assessments for pressure ulcers 6 were graded as red (79% or below) 3 were graded as silver (80-90%)and 5 were graded as gold (90-100%).

Staff followed appropriate policies and guidance when risk assessing a patient’s nutrition and hydration requirements.

People’s experience

Patients we spoke with on assessment felt they had enough room around their bed and on their ward. Between May and August 2024 the Friends and Family Test (FFT) Inpatient satisfaction score was reported as 93.8% reflecting an improvement over the last 2 years. The National Inpatient Survey 2023 reflected a high level of satisfaction for patient experience with feedback placing the trust 10th of 120 acute trusts surveyed.

Feedback from staff and leaders

Staff reported on the whole they liked the layout of the new hospital and it allowed them to care routinely for 6-8 patients. Staff told us they had access to equipment when needed including resuscitation trolleys, hoists, falls equipment, computers and observations machines.

Staff on one ward raised concerns that patients in the temporary escalation space did not have access to toilet facilities and an electronic call bell. We raised this with senior staff; they told us the trust were currently reconfiguring these areas to have electronic call bells and cubicle curtains installed within the next 3 months.

Staff told us patient flow and discharge was a problem on some wards. One ward had implemented a QI project and proactively identified patients most suited to that ward for transfer from AMU resulting in a more efficient flow of patients from inpatient to community setting. Staff told us reducing the length of patient stay had reduced falls and pressure sores in the ward and increased discharge rates.

Observation

The layout of the wards in the new hospital was consistent throughout with areas separated into four zones with each zone having 6-8 private rooms with en suite bathroom facilities. The wards were accessed via one zone. Entry to the ward was via an intercom system or electronic pass. A button was pressed to release the doors on exit.

The environment was well maintained. Corridors were clear of unnecessary equipment and fire exits were clear. Corridors and rooms were observed to be clean and fire extinguishers were labelled clearly and in date.

Equipment including hoists, clinical equipment and computers were observed to be cleaned and dated with ‘I am clean’ stickers and PAT tested. Emergency trolleys were spot checked on different wards and found to be sealed, cleaned all equipment inside was in date and complete. Related check lists were completed in full. Oxygen cylinders were placed at appropriate points throughout all wards and observed to be in date. An oxygen cylinder on two wards was noted to be nearly empty and which we highlighted to the ward managers at the time.

Electronic monitors outside of each room and boards in the patient rooms advised staff of any patient specific requirements such as the patient’s nutritional needs or risk of falls. Some rooms were observed to have information detailing preferences to let staff know what food the patient liked and hot drink preference.

Where infection risks existed monitors displayed the risk and minimum required level of personal protective equipment (PPE) required to enter. PPE was available outside the room door and means of appropriate disposal noted.

Information boards on all wards were observed to be up to date and displaying required and actual staffing levels. Staff had individualised notice boards providing information for staff, patients and relatives on topics such as end of life care, living with dementia, pressure ulcers, freedom to speak up, infection prevention and control and details of the Patient Advice and Liaison Service (PALS).

Hand gel was present throughout the wards and staff were observed to use it appropriately. Control of substances hazardous to health (COSHH) was observed to be stored securely and properly. Suitable COSHH risk assessments had been undertaken and were available to staff as a source of reference.

Call buzzers were observed to answered swiftly throughout all wards and all staff wore appropriate uniforms and noted to be bare below the elbows.

Computers for staff use to access patient records were lined up along the corridors outside of the patient rooms. They were observed to be locked when not in use.

On ward 6C and 6D prescribed thickener for fluids was observed to be accessible to patients and not in a lockable bedside cabinet. This presented a choking risk and was escalated to senior leaders who ensured the thickener was removed and locked away.

A sample of medicine refrigerators were checked; we noted temperatures logs were recorded and completed in full.

We observed call bells were in easy reach of patients and placed in bathrooms suitable for patients to reach.

Staff took pride in their ward areas and The Liverpool Quality Assessment (LQA) was observed to be embedded in each ward, with staff and leaders taking pride in their progress and working toward their next goals.

Processes

Liverpool Quality Assessment audits were carried out in clinical areas across the trust and discussed monthly between matrons and ward managers. Actions were identified and supportive measures taken. Concerns highlighted at the time of audit were escalated to the ward managers and an improvement time frame given. For the (LQA) environmental safety audits and patient safety audits for 17 medical wards; 6 were graded as red (79% or below), 6 were graded as silver (80-90%), and 5 were graded as gold (90-100%).

Peoples experience

Patients we spoke with on assessment were asked to comment on staffing. Just over half of the patients we spoke with felt there are enough staff on the wards and gave comments such as “well-staffed” and “100%”. The rest reported there should be more staff and gave comments such as yes “especially for additional patients in ward areas”, staff are “very busy” and “not enough at night”.

Feedback from staff and leaders

Following the move to the new hospital building with single rooms, staff told us that the number of staff on the wards had increased to ensure safe oversight of patients. Ward managers reported that generally wards ran at the full compliment of planned staff who were allocated to cover ‘zones’. When staffing was below the planned ratio or additional staff were needed. the on-call matron could be bleeped to reallocate staff from other clinical areas to support. A ward manager told us they did have a recent informal staffing review which showed more healthcare assistants were needed and this had been escalated to the leadership team.

Other ward managers told us they had recently recruited so had adequate staff to fill the rotas. All staff reported the dependency of patients was increasing and this affected staff availability.

Staff reported staffing levels as generally OK, the workload was manageable and they routinely received their breaks. Due to the new ward layouts, medical staff and allied health professionals were based in the ward areas. Staff reported they had good access to medical staff and allied health professionals for patient care and advice. Medical staff were contacted via the beep or telephone overnight and patient need was prioritised so those who were poorly were reviewed first. This resulted in a wait to be seen for some patients with less urgent needs. Staff told us medical staff were approachable and that they contributed to ward rounds.

Patients who required one to one care were allocated a staff member from a central resource on a risk basis. During periods when there were not enough staff available, ward staff stepped in; this presented a strain on the remaining staff members for patients requiring regular care. Due to each patient having an individual room, cohorting patients together in a bay was not possible. However, some wards had an activities room and co-ordinator and patients could come together to undertake activities to promote wellbeing and independence.

New starters and international staff spoke highly of the induction and/or preceptorship process. Staff told us they felt supported in their learning and development. Ward managers told us supernumerary time and learning was respected and staff concurred. Senior managers told us the preceptorship programme had achieved the Gold Standard of the National Preceptorship Framework and was awarded the National Preceptorship Interim Quality Mark in March 2024.

Staff told us generally their senior managers were visible most days. Staff reported their ward managers were supportive, visible and approachable and they would be happy to raise concerns to them.

Ward managers had regular 1:1’s with matrons to outline areas of development and support individual learning. Clinical supervision was offered to all staff and an electronic app was used to record the meeting and sign off staff competence.

Observation

Staffing charts were clearly displayed on all wards denoting planned and actual staffing levels. Overall wards had the planned level of staff present on the days of inspection; there were occasional instances of staffing being slightly under the planned level. Managers acted appropriately where unanticipated absence had occurred and staff were transferred from other areas where appropriate. There was a process in place to obtain additional staff for patients who required one-to-one care. Staff were observed to take their breaks on time.

Medical staff and allied health professionals were present and visible on the wards and liaised with nursing staff to enable treatment to be provided at optimum times for the patient. For example, patients were given their medicines prior to being supported to mobilise with physiotherapists. We observed staff encouraging patients out of their rooms to interact with other patients in activity rooms.

Staff training competencies were displayed on notice boards on most wards along with student skill levels. This supported staff to be confident asking students to participate in patient care, dependent on their level of training.

Processes

Training policies were available; there was a comprehensive list of mandatory training modules for each staff role. The trusts attainment in mandatory training was 89.66% at the time of assessment, with an upward trajectory which was just under the trust’s target of 90% compliance. The medical division was at 90% for all staff groups.

Role and core specific training for medical and dental staff had a compliance rate of 76% and nursing staff 89%. Leaders recognised further support was required to enable staff to achieve the compliance target of 90%.

Mandatory sepsis training for staff in specific roles (level 1) compliance was 95.02%, but for staff in non-specific level 2 roles compliance was slightly below 90% at 89.59%.

Some areas demonstrated significantly higher compliance than others with mandatory training such as ward 6C with the ward manager reporting 98% Mandatory training compliance and 95% for role specific training compliance.

Most nursing staff had completed Advanced Life Support (ALS) and 73.08% of medical and dental staff. Excluding doctors, there was an 88% compliance rate for completed appraisals for staff who worked in the medical division.

Peoples experience

Patients we spoke with on assessment reported wards appeared clean and staff came into rooms two or three times a day to clean them. Most could recall being screened for infections prior to or when they were admitted to the ward environment.

Feedback from staff and leaders

Staff told us infection prevention and control (IPC) issues were easier to manage due to single occupancy rooms. The electronic screens outside the rooms denoted any IPC issues and were kept up to date by staff. Ward managers told us electronic patient records allowed staff to view screening results prior to the patient being admitted to the ward, particularly if they were admitted via the emergency department or acute medical unit. This allowed staff to prepare for the patients’ admissions with the correct level of PPE being available.

Staff we spoke with did not raise any concerns related to infection prevention and control. All equipment was routinely cleaned and tagged overnight to ensure it was ready for use the following day.

Observation

Patient areas and corridors were observed to be clean and tidy. Cleaning records were up to date and staff were seen cleaning and tidying throughout visits to various wards. There were hand wash sinks placed throughout the wards and hand sanitiser and soap units present and full and available for use.

We observed where patients were being treated for an infection, or were at risk of infection, electronic screens contained the relevant detail to indicating the risk and required level of personal protective equipment (PPE) required. Staff were observed to follow IPC in place. We observed staff cleaning and tagging equipment to indicate when it had been cleaned.

Wards had noticeboards providing an update regarding IPC including information regarding recent cases of infection. LQA boards displayed information around IPC clearly for staff and visitors and staff took pride in aiming to improve these internal ratings.

We did observe some staff who were not “bare below the elbow”. Senior leaders told us they had reiterated the back to basics and bare below the elbow campaign message to all staff during the inspection and we witnessed staff who did not comply being challenged by leaders.

Processes

The trust had appropriate policies for infection, prevention and control practices, including an outbreak control and ward closure policy and a decontamination of reusable medical devices policy.

The premises and equipment were kept visibly clean and hygienic. Cleaning records were up-to-date and demonstrated that all areas were cleaned regularly, and equipment was cleaned after each patient contact. We observed staff following infection prevention and control principles, including the use of personal protective equipment, effective handwashing and being bare below the elbows. Hand hygiene signage was displayed throughout the department.

The department monitored key metrics in relation to infection rates, including MRSA (Methicillin-resistant Staphylococcus aureus), MSSA (Methicillin-susceptible Staphylococcus aureus) and E. coli (Escherichia coli). All patients were screened for infectious diseases when a decision had been made to admit them or if they were displaying symptoms. Results were then made available to staff and any infectious cases were followed up by the sites infection prevention and control team.

The site was performing worse than the required trajectory for all infection KPIs and reportable infections (as of October 2024):

• MSSA bacteraemia – 12 cases against an internal year to date (YTD) threshold of no more than 10.5 cases.
• CDI (Clostridium Difficile) - 64 cases against a YTD threshold of no more than 33 cases
• E. coli – 55 cases against a YTD threshold of no more than 54 cases
• Klebsiella – 32 cases against a YTD threshold of no more than 19.8 cases

Staff undertook IPC training as part of mandatory training. Training compliance for level 1 was at 93% compliance, however it was 80% for medical staff. Training compliance rates for level 2 were at 86% for nurses and 68% for medical staff.

The ward Quality Assessment (LQA) infection control audits for 17 medical wards showed 2 were graded as red (79% or below), 7 were graded as silver (80-90%), and 8 were graded as gold (90-100%).

The division actively supported the 'Gloves off campaign' encouraging staff used gloves appropriately and promoted hand hygiene. We saw posters were displayed in clinical areas to encourage staff to comply with this.

IPC link staff worked across the division and acted as advocates for good IPC practice. IPC resource packs were available in clinical areas to support staff and quarterly IPC meetings were held with link staff to review infection rates and share best practice.

Patient experience

Patients varied in the length of time they had been on the wards from less than a day to 9 weeks.

All patients reported that staff had taken time to get to know their wishes and preferences. For example, “They are very familiar and aim to respect wishes and preferences” and “they talk to me and ask what I like”

75% of patients reported they have been visited by their consultant or medical doctor every day with 25% saying weren’t sure this had been every day.

People were encouraged to administer their own insulin following a risk assessment. We saw that this was done safely.

Medicines for the treatment of Parkinson’s Disease were given at their specified times.

We saw one person was prescribed a high-risk medicine to treat their mental health which was not available at the Trust. The pharmacy team supported the safe administration and ongoing supplies of this medicine.

Feedback from staff and leaders

Staff told us that one person had their medicines added to yoghurt. This was not recorded in the patient notes. It was unclear if actions had been taken to ensure this was done safely.

Staff knew where to find medicines-related policies and guidance and how to access medicines out of hours.

When people were prescribed an antimicrobial, to treat an infection, there was not always evidence of a timely review of the medicine as per the Trust guidelines which may impact on the effectiveness of antibiotics.

Audits completed by the Trust showed an improvement of the administration of time critical medicines and the storage and handling of controlled drugs.

Observation

We found in most cases medicines were stored securely within the medicines rooms on the wards. However, we did observe some medicines including topical preparations were not always stored securely. We found that on 2 wards, thickening powder for people with swallowing difficulties was not stored safely as per Patient Safety Alert in 2015. It was not kept out of sight and reach as per the Trust guideline.

We saw that emergency trolleys were checked regularly. However, on one ward, the required weekly check had not been completed on one occasion.

Processes

We saw one person was given numerous doses of rapid tranquilisation (an injectable medicine to help calm a person who is distressed). Staff did not always follow the Trust’s policy and guidance from the National Institute for Health and Care Excellence (NICE) regarding monitoring and observation of the person following rapid tranquilisation. This placed the person at risk of harm.

Risk assessments for venous thromboembolism (VTE) were completed and medicines were prescribed appropriately.

Records of fluids given were not always complete and accurate and it was not always possible to determine what fluids were added to intravenous infusions. We found no records of thickening powder being added to drinks for people with swallowing difficulties.

Medicines records were not always updated to ensure the route of medicines administration was correct. There was a risk that medicines could have been given via the incorrect route.

A robust process was not in place to ensure oxygen was always prescribed which could impact patient outcomes.