Queen Alexandra 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

At our last inspection we rated this key question requires improvement. At this inspection the rating remains requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulations for learning disability training and safe environments.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

All staff we spoke with knew what incidents to report and how to report them. There was dedicated training on reporting incidents and the policy to support it was available to staff on the intranet. Staff reported all incidents in line with policy. Where possible, staff were debriefed and received support after a serious incident. We spoke with staff who told us ‘Hot’ debriefing sessions happened soon after incidents, to discuss the incident and to provide wellbeing support. Further ‘cold’ debriefs were also initiated by leaders to identify ongoing concerns or learning opportunities. These debriefs were then fed into incident investigations.

Daily huddles occurred, these included departmental matrons, and governance leads and discussed ongoing incident investigations, shared relevant updates and next steps to be taken. Also, the first meeting of the week was longer, to include incidents reported over the weekend. This meant if immediate actions from incidents were needed, leaders and staff could rapidly implement these.

Additionally, there were weekly patient safety meetings to discuss newly reported and ongoing incidents in detail. Patient safety cases that had been raised were escalated from this meeting to the Trust Patient Safety Incident Review Groupfor investigation.

The department shared learning outcomes during staff handovers which happened 4 times a day. Leaders facilitated a monthly Mortality and Morbidity meeting. Staff members were encouraged to attend and discuss both positive experiences and incidents from which the department could learn from. This was shared through digital and visual communications, and during staff meetings. Handover headlines were discussed twice daily in huddles to ensure all staff shifts were informed of essential information and learnings. We reviewed materials shared in these meetings and saw that they contained a range of patient safety and practice education messages. For example, learning relating to aortic aneurysms and dissection and what red flags to look for. Leaders told us patient journey stories were shared to improve understanding of the patient experience. We also heard how lessons learned from an incident prompted changes to the pre alert system. Following the incident, all pre alerted patients went directly to resus and then were ‘stepped down’ to majors when appropriate. This meant pre alerted patients were triaged sooner and could access more timely treatment.

Staff told us violence and aggression from patients and their carers was a commonly reported incident. We reviewed all incidents related to this in the 12 months prior to inspection and saw that where possible learning outcomes had been actioned and communicated to staff involved.

However, data we reviewed showed there were 3,318 incidents reported by staff in the 12 months prior to inspection. The most reported incidents were capacity issues, and this represented 48% of all incidents reported from November 2024 - May 2025. We reviewed 50 moderate or greater harm incident summaries from the Adult Emergency Department. Of these incident investigations, 5 had been completed, 14 incidents were pending final approval and 31 were still being investigated. Additionally, there were 3 incidents with open investigations for over 6 months. Of these incidents, all those related to capacity issues were yet to be completed. We also reviewed 6 incident summaries from the Emergency Care Centre from the time period of November 2024-May 2025. Of these incidents, no investigations had been completed in full. The oldest incident that had not yet been completed was from December 2024. We saw no evidence to detail how specific updates had been communicated to staff in the time since these incidents had been reported.

Frontline staff did not always feel they received updates for ongoing incident investigations in a timely manner. Sometimes, when incidents related to wider concerns, such as capacity or patient flow, these were not always discussed with staff directly. This led to some staff feeling that their concerns were not escalated and acted upon. In the case of capacity concerns leaders told us how this fed into wider work being done within the trust to improve flow and therefore work to resolve this may not feel to staff as personable as when they reported specific incidents.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Staff involved all necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and following discharge. The urgent and emergency care department utilised a separate patient records system to the main hospital. When a patient was admitted to a ward, an electronic record of the patient’s emergency department notes was sent into the main patient records system. This included relevant information such as details of ongoing treatments and discharge planning if needed. This meant essential information was available to all staff to facilitate joined up care.

Staff directed patients to other services when appropriate and, if required, supported them to access those services. Patients who attended the emergency department for treatment that could be sought elsewhere, for example through their GP, were redirected.

In urgent and emergency care, a discharge checklist had been implemented to outline essential information that patients and their care givers should be informed of, at the time of discharge. This included safety checks, such as ensuring cannulas had been removed, ongoing medicines provided and the most recent clinical observations. This checklist had been discussed in handover headline meetings to ensure it was well understood by staff. Leaders and staff from discharge planning told us this was working well and positively received.

If a patient was discharged directly from the urgent and emergency care department, discharge information was sent electronically to patients’ GPs. This meant GPs were aware the person had been in hospital advised of any ongoing treatment and prescriptions required to continue care. If an electronic discharge summary could not be sent electronically, this was printed and sent by mail. The service told us that discharge summaries contained results of investigations, the reason for admission (diagnosis), details of the treatments given and recommendations for follow-up care. Follow-up care recommendations included referrals to specialists and additional testing necessary for continued patient recovery. Patients or their care givers were provided with a printed discharge summary.

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

Staff we spoke with knew how to make a safeguarding alert and did this appropriately. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. We saw evidence of safeguarding referrals made by staff at the service. These were made in line with policy and escalated to the appropriate services. In the 12 months prior to the inspection, there were 507 adult referrals and 620 referrals for persons under 18.

Staff we spoke with told us that safeguarding concerns were routinely discussed in safety huddles and meetings. We saw evidence of learning and outcomes from safeguarding referrals being shared with staff. For example, the March 2025 update focused on domestic violence referrals and the outcomes achieved. This meant staff could be assured their concerns were actioned and vulnerable person were safeguarded effectively. Staff spoke positively about the safeguarding team and the work they did to support patients and staff.

Staff followed safe procedures for children visiting the service. This included a dedicated paediatric emergency department which was securely accessed to ensure the safety and privacy of all children and young people using the service.

Team leaders oversaw compliance with training, which included discussions at appraisals and in monthly 1 to 1 meetings. The department safeguarding leads gave face-to-face training in Level 2 safeguarding training for adults, and Level 3 update training for child safeguarding.

The trust advised that the target for completion of safeguarding was 85%. However, data supplied by the service showed that not all staff had undertaken mandatory training in safeguarding. We saw staff who were required to undertake adult safeguarding training in level 1 & 2, and for children level 2 this met the target. But for level 3 adult safeguarding this was below target at 62%.

Level 3 training in child safeguarding is usually required in staff who have a significant role in safeguarding children, including those with direct responsibility for investigating, reporting, and recording safeguarding concerns. However, the level of compliance with this training was below target at only 51%. Overall, the combined percentage of staff who had completed training aligned with their clinical role was 81%.

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

Patient record systems recorded how long patients had been waiting to be seen since arriving, and their clinical priority. The service aimed to triage all patients within 15 minutes of attending the department. At times of high demand, this was not achieved. Staff told us increases in demand meant they could not always meet this target. We saw patients waiting beyond 15 minutes throughout our inspection. Time to triage (TTT) data between February and April 2025 showed the average TTT exceeded 15 mins. However, this was by a small amount of time. For example, in February 2025 - 18 minutes, March 2025 - 17 minutes, April 2025 - 16 minutes. The trust advised that TTT was discussed in clinical and operational huddles, site assurance meetings, and monitored by the care group team. We were told these would be escalated if they indicated there were concerns.

Patients attending via ambulance were reviewed and triaged in a dedicated Rapid Assessment and Treatment (RAT) area upon arrival. A senior ED doctor or advanced nurse practitioner led decision making in this area. This was to ensure timely senior clinician assessment, early recognition of critically ill patients, and prompt initiation of necessary investigations and treatments. Leaders advised us that all patients arriving via ambulance or walk-in with time-critical presentations should be considered for RAT. However, during our assessment we saw periods where a medical doctor did not staff this area. Instead, patients were assessed solely by the nurse who was also in charge of also managing ambulance intake. Staff told us there was not always a doctor available for this area. This meant some patients did not receive a review upon admission, which could delay timely care and treatment.

The latest NHS England data, in February 2025 showed 36% of patients at the trust, were treated within 60 minutes compared with 22% for England and the South-East Region. However, in January 2025, only 65.6% patients at the trust were seen within 4 hours, this was below the England average of 73%. This meant less patients had a decision about their overall care planning within 4 hours compared to the national average. Throughout our assessment we saw patients who had been awaiting a medical review for over 12 hours.

The department had 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.

When patients were seen staff communicated with patients so that they understood their care and treatment. The trust used the National Early Warning Score (NEWS 2) to assess adult patients at risk of deterioration which supported staff to take appropriate action. In the paediatric department, staff used, an acuity tool approved by the Royal College of Paediatrics and Child Health (RCPCH). Staff could describe how to escalate patients that needed clinical review.

However, the department did not undertake any audit monitoring of either the adult or paediatric acuity tools to measure effectiveness and compliance. This meant leaders could not identify whether these tools were used well or if there were areas for improvement. The service did not demonstrate effective oversight of patient acuity and deterioration. This posed a risk to patient safety.

In addition to this, we reviewed 10 sets of nursing records and found they contained omissions of care records and poor documentation. There was minimal documentation of nursing care and poor compliance with fluid balance records. We also saw instances where staff did not increase how often they monitored and recorded observations following increased NEWS 2 scores. This did not comply with national best practice guidance and local policy, which meant patients who had become increasingly unwell were not reviewed as frequently as they should have been. There were also omissions in medical clerking, and poor compliance with insulin administration records. Omissions in insulin administration records meant patients with diabetes were at risk of not receiving the right amount of insulin. We raised these issues with the provider directly. Following the inspection, leaders increased observation and auditing of nursing records to highlight areas of poor compliance. We were also told that, following our inspection the ED Practice Education Team had conducted a nursing documentation scoping exercise to improve nursing documentation

For children and adults that self-presented to the emergency department there was a triage process in place to determine patient clinical priority. A team completed this process which comprised of nursing support staff, registered nurses and a doctor. This team was responsible for escalating cases that required admission. This opportunity was also used to redirect patients to alternative services, such as the Urgent Treatment Centre, Emergency Care Centre, or Urgent Primary Care.

Clinical staff did not perform manual restraint on patients and people at the service. If manual restraint was required, this was undertaken by security staff. Security staff had received training in how to manage violence and aggression, de-escalation and least restrictive restraint. The trust advised this training was refreshed annually and was certified as complying with the Restraint Reduction Network’s training standards.

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

The department was often crowded, with patients cared for in inappropriate spaces such as corridors and non-clinical spaces. Corridor care made it difficult to use necessary medical equipment such as portable patient monitoring devices and emergency equipment. In addition to this, these spaces had no dedicated areas for personal care and only 1 toilet at the end of the corridor which had 28 bed spaces. There were also no patient call bells. This created a falls and ongoing safety risk to all patients in this area. We heard from staff how in the weeks prior to our inspection, a patient had fallen from a temporary bed space in this area which resulted in a serious injury.

The corridor was continuously brightly lit and offered no privacy. Whilst staff were aware and managed some risks of corridor care, the environment in the cohort areas were not appropriate for patient care. The environment also reduced the space for other patients being moved through the areas or being brought in by ambulance. The use of this corridor to hold patients also meant that in the case of an evacuation movement of beds from other areas such as majors could be delayed. The service had not undertaken scenario training for fire evacuation since moving to the new building. All staff we spoke with throughout our inspection told us their main concern was delivering corridor care and capacity.

During our assessment we saw how laminated cards had been applied to walls in the corridor to assign these as designated patient spaces. Throughout our assessment, we saw patients being cared for in the corridor despite having mobility restrictions and fall risk alerts on their electronic record that meant these spaces posed a risk to their safety.

There was no clearly defined policy in place to identify risk restrictions for patients in this area beyond infection prevention and mental health crisis. During our assessment we saw a patient who was attending the department via ambulance, they did not speak English as their first language and had a diagnosis that affected their level of comprehension, despite these potential safety and communication concerns they were placed in an escalation area due to lack of capacity in other areas. We also observed a patient in an escalation area that had an increasing National Early Warning Score (NEWS). The National Early Warning Score (NEWS) 2 determines the degree of illness of a patient to prompt response and intervention. Staff were not aware of this and took action to move this patient to the resus area when we raised this.

Urgent care team staff strongly opposed the use of the corridor for patient care. Staff told us how they had agreed to deliver care to a maximum of 6 corridor spaces, for patients who fit a strict set of criteria. This was a compromise due to the wider pressures of the increased number of patients accessing the emergency department and to support rapid offloading from ambulances. However, staff said this had since developed into the use of 28 corridor spaces, all of whom had varying levels of acuity, which they felt represented a large patient safety risk. We also saw evidence of staff and leaders raising concerns around the high risk of missing pathology due to the limitations of these spaces. All staff we spoke with told us they felt helpless when it came to patients being in escalation areas who they felt should not be there.

In the Emergency Care Centre, there were spaces available for up to 12 patients overnight. This was due to the fact that chairs were removed from waiting areas to increase capacity in the evenings. However, this meant these spaces did not have access to call bells which meant patients were not easily able to call for help when they needed it. There was also access to 1 toilet and no showering facilities. The ECC was located to the side of the main hospital and exited onto a road. Staff told us they were concerned that the location of the area meant that the door to the department lead directly outside, which could be a risk overnight if patients were confused and tried to leave. We heard that there had been instances where patients had become confused, got out of bed and walked out of the hospital. We reviewed the risk register for the department and saw that the remote location and use of ECC had been documented by leaders as 2 separate risks in April 2025. There were mitigations documented including the development of a standard policy to determine patient suitability. However, this was not yet in place at the time of inspection and no immediate actions had been taken to reduce ongoing risk.

In Resus, Majors and Adult Urgent care, there were dedicated single space patient areas that were spacious and offered privacy and good patient care. Staff utilised computers on wheels (COWs) to ensure they could remain in these areas while undertaking patient charting and ensure constant supervision. There was also mixed care area in the major’s area, this was spread over 4 dedicated sub wait area which each had 4 recliner chairs. There was also a seated sub wait area in adult urgent care which held 4 patients. This area also had recliner chairs, however it was cramped and offered little privacy. There was also a disabled toilet in the corner of this area which was poorly accessible when all patient areas were in use. There was an accessible toilet in the main waiting area, which also had a changing places bathroom. However, to access these a wheelchair user would require the support of a staff member to open the door back into the waiting area as doors were not power assisted. This meant the environment was not always well designed or utilised for the needs or comfort of patients using it.

There were separate areas in the department to care for people who required support and treatment for their mental health (MH). This was intended to provide a more private and dignified patient experience. However, Specialist mental health staff told us the rooms did not conform to best practice standards and guidelines such as Psychiatric Liaison Accreditation Network (PLAN) standards. These had been presented to the trust before the department had opened to support creating spaces that met these standards. We observed how 1 of these areas contained significant static ligature risks from piping in both corners of the ceiling. Also, the doors to the room did not open in both directions. This meant if patients attempted to self-harm and blocked these doors, staff would not be able to enter the room. Additionally, all MH assessment rooms contained tannoy speakers that could not be muted and could add to patient distress. The additional MH crisis space in use at the time of assessment also had a broken sink and damage to wall areas. In the paediatric assessment room, there was an oxygen attachment plugged into the wall outlet which could be used as a ligature point. We alerted staff to this, and they removed the oxygen outlet in the paediatric room.

Staff told us the ligature risk and additional concerns with the new mental health assessment spaces had been raised and escalated to leaders on multiple occasions since the department had opened in November 2024. We also heard this had also been escalated to leaders by staff who worked for specialist mental health NHS trusts. All staff told us they had not seen any changes made as a result of raising these concerns. We reviewed the risk register for the department and saw that there were 2 separate risks escalating the concerns regarding ligature points and lack of PLAN compliance.

At the time of our assessment there were no risk assessments in place for any of the mental health assessment areas. These shortfalls in the design and management of specialised mental health treatment areas presented a risk of ongoing and increased harm to vulnerable patients.

Following our inspection, leaders said works had been undertaken to ‘box in’ piping in these areas. We were provided with risk assessments for these spaces that were undertaken following our inspection. These assessments gave details of mitigating actions to be taken to keep patients safe while they were in these spaces. However, there was also no clear timeline in place to complete works removing all ligature risks fully and to make the assessment rooms PLAN compliant and in line with national guidance. This meant the trust could not be fully assured these spaces were safe for patient use prior to our inspection and they remained not in line with national best practice standards.

The paediatric ED was a separate department for children and families. In the main area there was adequate space and there was no overcrowding in the department during our assessment. Within the main department there was a central nursing station which supported constant direct audio-visual monitoring of patients.

There was a direct passage of access from the paediatric ED to the radiology department, meaning that these patients would not have to encounter adults if they required diagnostic imaging. However, when patients were admitted from the paediatric ED to a ward, they would be taken through a space which also held escalation area patients and their families or carers.

Most environments were designed to be accessible and supportive. This included ramps, handrails, and easily navigable spaces that allow individuals to move freely and safely. However, these were not always well designed. Hand washing facilities were often placed close to toilets, despite large empty spaces in front of mirrors, this was seen throughout the department. This meant the space needed to access the toilet was restricted and may pose a risk to people with mobility conditions.

The adult waiting area contained 32 chairs which were closely placed together. This waiting area often became crowded with little personal space between patients. There were no designated areas for patients in wheelchairs which posed a risk of blocked walkways in seating areas. We observed patients in wheelchairs struggling to find a safe waiting space that they felt did not impede the movement of others. Patient feedback also raised this concern.

The chairs in the adult main waiting area were a mix of high and low back chairs. During our assessment we heard from several patients who had been in this area overnight who spoke of discomfort and ‘bad backs’. We also received feedback prior to our assessment from family members who raised concerns about the comfort of patients waiting in this area for long periods of time. During our assessment, we observed an instance of patient collapse in this area; staff took measures to shield the patient by moving screens which previously surrounded the triage area. Due to the close proximity of all patients and size of this area, sensitive medical information including reason for attendance could easily be heard by other patients.

We saw how patients received care and treatment in waiting areas, such as intravenous medicines. Staff were unable to move these patients into areas designed for care and treatment as they were already fully occupied. Staff told us this frequently occurred. This meant patients sometimes received care and treatment in an environment that did not promote dignity and was not designed for the care and treatment that was being delivered.

Staff told us there has been numerous instances where the number of patient and their families in this area exceeded over 100 people. We also received numerous patient feedback concerns where patients reported they had stayed in this waiting area for extended periods of time and in some cases overnight. Data we reviewed supported that this occurred frequently. We reviewed data for the 3 months prior to assessment which showed that the average number of patients, waiting overnight between 12am-7am in this area was 29, this did not include anyone attending with them. There were 297 instances, in any 1-hour period between 12am-7am from 1st February- 18th May 2025 inclusive, where patients waiting in this area exceeded the number of seats. Data also shows that the highest occupancy of patients waiting during this period, when counting only patients and not anyone accompanying them, was 72.

Staff told us they felt this area was not big enough to function in the way it did currently. However, if it was functioning in the way it was designed to, with effective streaming and flow than it would be more than adequate. Although staff and leaders were able to see the number in patients waiting in each area, they were limited in taking steps to reduce the numbers waiting due to poor patient flow. Services that some patients may be redirected to, such as ECC or UTC, were also not available overnight. This was further impacted by poor flow from the adult’s waiting area into the adult emergency care department.

There were no formal risk assessments to manage overcrowding or an identified maximum safe occupancy limit for the adult waiting area or any other areas in isolation. Fire assessments undertaken in the department focused on solely on capacity of the whole UEC building, and not individual areas of the department. This meant the department was unable to safely manage or have oversight of overcrowding risks in the adult waiting area.

The department had opened in November 2024, and fire safety and other emergency systems were tested and maintained. However, in all areas, we saw fire evacuation plans that were not adequately fixed to walls and were temporary carboard images that remained from during building works and were leant against surfaces. Staff had also not undertaken any fire evacuation scenarios.

The facilities were otherwise well maintained, and any equipment used with patients was in good working order and used safely to support the delivery of safe care. Hazardous and clinical waste was responsibly managed. Staff wore personal protective equipment in line with trust policy when patients were immunocompromised or posed infection risk. Staff had also undergone scenario training for major incident response.

Records of maintenance and portable appliance testing were held centrally. All the equipment we checked in the department including emergency equipment appeared clean and had been tested.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Overall demand for UEC at the service had increased since February 2023. The total number of attendances for all A&E types was 8.5% higher in 2024/25 than it was in 2023/24. This increase of 8.5% was higher than observed across England (5.9%). Senior leaders told us staffing was planned in advance to anticipate the levels of staff required. This was to ensure planned staffing was sufficient to maintain staff to patient ratios and considered risks associated with staff shortages. The department also used a Safer Nursing Care Tool (SNCT) alongside patient metrics to determine and plan staffing levels. The tool used by the trust was in line with National Institute for Health and Care Excellence (NICE) and NHS England (NHSE) guidance.

When necessary, managers deployed temporary staff to meet safe staffing levels. When this occurred, nursing staff from the NHS Bank staff were prioritised and the Trust did not employ any agency nursing staff. This was to ensure staff were as familiar with the trust policies and process as possible. On the day of assessment 9.8% of medical shifts were filled by locum doctors. Leaders told us that the trust would be undertaking a benchmarking process to compare the findings of the SNCT acuity findings against recommendations from the RCEM.

During our inspection we reviewed nurse staffing levels for the day and saw this showed the number of registered staff matched planned numbers. However, non-registered staff levels were below planned numbers. During February and March 2025, both registered and unregistered nursing staff levels in both adult and paediatric departments were below planned numbers. In April 2025 staffing levels for adult emergency care were also below planned numbers. This meant the service did not always make sure there were enough nursing staff for each shift.

Nursing staff told us that they worked on a ratio of 1 nurse to 6 patients. During our inspection we saw that nursing staff had patients allocated via whiteboards and this did not exceed 6. However, staff reported that nurses cared for more than 6 patients in the corridor spaces when there was increased emergency department attendance. Changes to ambulance arrivals meant that rapid admission in the UEC could not be controlled by ED staff. Ambulance staff were required to handover patients within 45 minutes. The dynamic nature of ambulance attendances meant that in some cases patients were allocated to escalation areas and nursing ratios exceeded 6 to 1. We heard from several staff members there were often times when they had been caring for more than 10 patients in escalation areas. We heard how as there were 28 corridor spaces, there was often periods where nursing staff were providing care at a 1 to 12 nurse to patient ratio.

We reviewed the average nursing staff to patient ratios for the 90 days prior to inspection. For 25 days during this period, the nursing to patient ratio exceeded 6 patients to 1 nurse. This meant that at times of pressure, nursing staff were caring for more than 6 patients on average at any one time. The days where nursing ratios exceeded 6 patients per nurse also directly correlated with days where the department had increased attendance.

Staff would escalate increased nursing to patient ratios to leaders, who would reallocate staff from other areas in the trust to majors and UEC staff moved to care for patients in the corridor. However, we heard from staff that this was not always rapidly achieved. Staff told us they felt that redeployment, due to escalation areas being used, created uncertainty and damaged morale to all staff. Staff described being sent staffing rotas where staff were allocated to escalation areas in advance. Despite this, the safe nursing ratio was exceeded an average of once every 3 days. Staff told us they felt that staffing overnights could be particularly difficult for nursing staff.

When staff were redeployed for the first time, staff members completed the Trust's local induction checklist in collaboration the nurse in charge of the shift. This checklist was designed to familiarise staff with the department, ensuring they were aware of with essential policies and procedures relevant to their roles. The trust had also redesigned the new staff induction checklist to ensure that new staff were orientated to the department in advance of redeployment.

Data we reviewed for non-consultant doctors also showed that on these dates, the numbers of patients being cared for by each staff member increased due to high attendance rates. Consultant to patient attendance data showed they were responsible for an average of 52 patients at a time. This increased with demand and on 3 occasions, consultant doctors were allocated over 75 patients. This was the same for all medical UEC staff and was directly due to the demands faced by the service which were dynamic and fast changing. This meant safe staffing levels could not always be accurately predicted. Hospital leaders said staffing was discussed regularly at staff huddles and urgent staffing requirements could be escalated through matrons. Unplanned staff absence was discussed in huddles with actions taken by leaders to source staff.

We reviewed data on staffing for the trust which showed that during April & May 2025 the staff sickness rate was 4.6%, this was below the national average of 4.9%. In March 2025 the Urgent and Emergency care (UEC) workforce monthly sickness rate was 4%, this was lower than comparable trust departments within the region. The most common reason recorded for staff sickness in UEC staff was stress and anxiety, this which was similar to other NHS Trusts in the region.

All NHS trusts are legally required to ensure their employees receive learning disability and autism training appropriate to their role. This is to ensure the health and social care workforce has the right skills and knowledge to provide safe, compassionate and informed care to autistic people and people with a learning disability. However, mandatory training in Learning Disability and Autism level 1 had only been completed by 41% of staff. For staff who required tier 2 training this had only been completed in 17.5% of staff. The trust advised that the ability for staff to complete tier 2 training was limited by the stakeholder who provided this training.

The trust provided 1 ALS and six online ALS courses per year. Two places on each course were allocated to UEC, more would be offered to nursing staff if spaces became available. Prioritisation for places was given to nursing staff within the trust to ensure the most appropriate staff received training. We were told how there was a rolling Programme of Basic Life Support which was overseen by the Practice Education Team. Basic Life support training had been completed by 93% of nursing staff in adult emergency care, and 93% of staff in paediatric emergency care. The high uptake in training was also credited to the department implementing ‘in house essential skills training days’. Intensive life support training had been undertaken by 44% of staff, pre booked training meant this was planned to increase to 57%.

Within UEC 72% of medical staff had completed training in Advanced Life Support (ALS). The trust told us that many Consultants and registrar-level doctors, were also ALS instructors. We were told that the trust ensured that all working shifts included at least 1 ALS-trained doctor. This was to ensure consistent access to senior resuscitation expertise. Nationally, Doctors who commenced training after 2021 were not required to undertake ALS training. Despite this, 59% of this staff group had independently completed ALS training which reflected a strong commitment to providing safe emergency care.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They also did not always detect and control the risk of it spreading.

During our inspection we saw that staff mostly adhered to infection control principles, including handwashing. Staff mostly followed infection prevention and control (IPC) guidance and washed hands between patient contact and wore appropriate PPE. However, some staff were observed completing patient records immediately after examination and before undertaking hand hygiene. In escalation areas there was also limited access to hand washing facilities and wall mounted hand sanitisers for staff, patients and their visitors. Additionally, in the adult urgent treatment area, 3 of the 5 wall mounted hand sanitiser dispensers were not functional. Staff advised us these had been reported.

Staff from the IPC team undertook audits to monitor compliance with IPC and identify areas for improvement. These audits showed mixed compliance outcomes. For example, the hand hygiene audit for February 2025 identified multiple areas of non-compliance and had a compliance rate of 68%. We reviewed an action plan created in response to this, with identified areas to improve compliance. The completion date for this was early March 2025. However, there was no evidence of the audit being undertaken again in March 2025 to determine if the action plan was effective. In addition to this, when this audit was repeated in April 2025, although compliance had improved overall, the same areas as previously identified such as undertaking hygiene before and after patient contact were 89% and still below a pass rate. Following our inspection the trust supplied an IPC plan which identified work that was ongoing to drive improvement around the areas where there was an ongoing lack of compliance with IPC issues.

The PPE audit for February 2025 also identified poor hand hygiene practice with 80% compliance. The action plan for this contained similar actions as the hand hygiene action plan with the review date set for mid-March 2025. We saw no evidence that this audit was undertaken in March or April 2025, so it was unclear how effectiveness or compliance with the action plan was being monitored.

We reviewed the compliance rates for the standard precautions audit, this looked at a range of areas such as linens, hand hygiene, and sharps. In February 2025 this audit also identified poor hand hygiene practice and cleanliness with a compliance rate of 85%. We reviewed the action plan for this and saw it contained improvement targets including staff communications, the review date for this was mid-March 2025. We saw no evidence that this audit was undertaken in March 2025, so it was unclear how effectiveness or compliance with the action plan was being monitored. In addition to this, although the audit undertaken in April 2025 showed improvement in some areas this was still below target at 87%. This audit also showed a decrease in compliance with cough etiquette. Following our inspection the trust supplied an IPC plan which identified work that was ongoing to drive improvement around the areas where there was an ongoing lack of compliance with IPC issues.

The results of the March IPC Audits were discussed in the March Quality Safety and Risk management meeting (QSRMM). The minutes showed no improvement actions for the areas falling below the expected standard in the audits. At the June QSRMM leaders did not discuss IPC audit outcomes, IPC action plans or the IPC plan supplied following our inspection, this was despite the concerns raised in the previous meeting. This meant that we were not assured that there was effective oversight of these audits or implementing effective improvement in IPC. This demonstrated leaders failed to effectively use monitoring tools to improve infection prevention and control practices.

In the escalation area, there was restricted access to bins, and we saw empty drink cups and food wrappers on chairs at the end of still in use patient trolleys. Patients were unable to dispose of these items themselves as their movement was often restricted. A patient told us they ‘did not feel able to bother staff to take them away as they were so busy’.

Staff reported patients who needed to be cared for in isolation due to infection or a supressed immune system, were provided with a single room to manage effective barrier nursing. At times when no single spaces were available, this was achieved by moving a patient from their single room into the escalation area. This process was referred to by staff as ‘requeuing’. Staff told us how they did not like to use this process as it posed a risk of deterioration to patients who had previously been stable in designated spaces.

Staff told us that when an infectious patient arrived by ambulance, it was expected that they would be held on an ambulance until a dedicated single use space was available.

However, we heard how, due to ambulance 45 minute handover targets, there were instances where patients who posed an IPC risk were offloaded immediately from ambulances before dedicated spaces were available. We also saw instances of this occurring during our assessment. Incident reports also demonstrated that this had occurred previously. When this occurred and no dedicated bay could be allocated, these patients were held in the assessment area until a space became available. Staff told us they felt unable to challenge this with ambulance staff directly as patients had already been offloaded. We did not see any evidence of this practice being raised by leaders with the ambulance service directly, to reduce this occurring. This posed a risk to the safety of all patients and staff as they were unable to ensure IPC risks were controlled effectively.

We saw staff undertaking thorough decontamination cleaning of a patient bay which had been occupied by an infectious patient. Staff ensured they donned the appropriate protective personal equipment (PPE) before undertaking this and disposed of this in line with policy. The service shared concerns with appropriate agencies promptly.

Patient admission areas such as majors and the adult urgent care area were clean, had required furnishings and were well-maintained. We saw housekeeping staff continually undertaking cleaning in patient areas such as patient bays. These areas were clean and well maintained. Housekeeping staff were friendly and respectful to patients including when undertaking cleaning in a patient bay while patients were present.

Staff maintained equipment well and kept it clean. Any ‘I am clean’ stickers were visible and in date. We saw staff cleaning equipment following patient contact and in line with policy. On mobile, non-patient contact equipment such as mobile computer stands, all ‘I am clean stickers’ were from the day of assessment, this demonstrated cleaning had been performed recently.

3. We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. They involve people in planning, including when changes happen.

The department maintained robust systems for the safe prescribing, administration, and storage of medicines. Staff followed good practice in medicines management and did it in line with national guidance. We saw that medication was stored safely and in appropriate areas. The UEC used an electronic medicine dispensing system. This system ensured all medicines were stored correctly and access was restricted.

There were staffing pressures within the pharmacy department, that affected timeliness of medicines reconciliation. All patients’ prescription charts reviewed were complete with necessary fields completed, such as allergy status. There was a dedicated medication advice and supply service available seven days a week.

Emergency medicines and equipment were available. There were tamper evident seals in place to ensure they remained secure. Staff recorded weekly safety checks on emergency medicines and equipment to ensure they were safe to use if needed in an emergency. All expiry dates we checked were in date. Fridges were monitored centrally by the pharmacy team and also monitored locally. We saw these records were accurately completed in full in all areas.

Training and competency checking for staff were comprehensive and consistent across all areas with mechanisms to investigate and report on medication errors and share the learning of such events. There was a clear presence of clinical pharmacists and pharmacy technicians contributing to medicines reconciliation and medication safety. Patient Group Directions (PGDs) were in place to allow for appropriately trained staff to administer medicines within a specific framework.

Across the department, staff demonstrated compliance with national guidelines including those from NICE and used nationally recognised tools to support safe and effective medicines management. Medicines reconciliation was monitored by dedicated pharmacists and pharmacy technicians who played key roles in this process. Pharmacy staff could remotely monitor stock and dispensing practices.