Queen Elizabeth Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also ensured that people’s liberty was protected when it was in their best interests and in line with legislation.

At our last assessment, we rated this key question as requires improvement. At this assessment the rating has improved to good. This was because we found there was a positive learning safety culture where incidents were investigated, and learning was shared and embedded to promote good practice. Staff we spoke with were open and honest when things went wrong, and they had the opportunity to learn and gain experience. The environment was safe and well maintained. There were effective mechanisms to adjust staffing levels when needed to keep the department and patients safe. Staff mostly demonstrated safe medicines management. Risks to patient safety were mostly mitigated. Staff did not always practice high standards of infection prevention and control. Some staff had painted nails and rings on and did not always wash their hands.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The 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.

The service ensured that lessons were learned, and improvements made when things went wrong. The service had a Patient Safety Incident Response policy in place which supported staff to identify which learning response would be the most appropriate depending on the patient safety event. These learning responses included patient safety incident investigations (PSII) and after-action reviews (AAR). Staff and leaders, we spoke with were aware of NHS England best practice guidance: Learn from Patient Safety Events (LFPSE). They told us they were encouraged and supported to raise concerns, and felt confident that they would not be blamed, or treated negatively if they did so. However, some staff felt that they didn’t report incidents that occurred frequently, such as verbal aggression, as the form was very long and they did not always hear back from incidents that they reported. Governance meeting minutes we reviewed identified that the senior team looked at incidents and highlighted any themes and trends. Incidents across the department and medical service were discussed so that learning was shared across these areas.

All staff described the ways in which information from incidents was shared with the department. This included the use of a private mobile messaging service group, emails, through a monthly newsletter and at handover. We were also advised that the noticeboards in the breakout rooms contained information on learning from incidents. However, we did not see a monthly newsletter, information in the breakout room or hear on handover about shared learning. Most staff used emails or the mobile messaging service group to make themselves aware of changes to practice following incidents. Staff described multiple mobile messaging service channels through which they received specific information such as training and development, social activities and notable news. Staff described that “hot” debriefs, those that happened as soon as practicable following an incident were more likely to happen than “cold” debriefs, those which happened sometime later when the incident had been investigated.

Staff were aware of the requirements for duty of candour and enacted this at a patient level when aware of a complaint or incident. The service used the learning from complaints and concerns as an opportunity for improvement. Senior members of staff and leaders were involved in reviewing complaints and incidents. For example, a leader within the Emergency Department (ED) told us that there had been a theme of complaints relating to the care of patients miscarrying whilst in the ED. In response to this a designated quiet area was allocated to patients who were at risk of miscarrying. This area had access to a private toilet facility. Staff were aware of this area and why it had been allocated for this type of care. The department now had a new pathway for patients who were miscarrying.

The risk register for the department shows 7 risks rated as high. This means that they scored above 16 in the risk scoring. These focused predominantly on the impact of poor performance of the department such as delays to care and treatment. These risks were regularly reviewed and had been so 16 days prior to our inspection.

Following incidents involving mental health patients, the trust will work with a mental health provider to decide whether to do individual or joint investigations. In November, a young person with mental health needs died after leaving the department. The trust has set up a group to review learning from this incident. They are reviewing all the data of absconding. Police liaison officer has arranged for the police team to visit and review the department. They are also considering how information on risk is communicated.

The evidence showed some shortfalls. The service mostly worked well with people and healthcare partners to establish and maintain safe systems of care. They made sure that there was continuity of care, including when people moved between different services. However, they did not always manage or monitor people’s safety. The service lacked oversight of the waiting area and did not always monitor patients’ condition whilst lengthy waits in this area. The service did not always apply wrist bands prior to further treatment being provided.

The department worked collaboratively with internal colleagues and external partners to maintain patients’ safety. Continuity of care was maintained by effective handover of patients and communicating their individual needs. All patients entering the department on foot were required to sign in on an electronic tablet and then at the reception desk. This would initiate streaming by the GP provider that runs the urgent treatment centre who would then refer the patient to the most appropriate pathway. Assistance was given to patients who struggled with this system. Following streaming, the patient either went to a third-party provider for GP services, mental health services or were sent to be triaged by the ED service.

Patients we spoke with did not always understand their pathway. Receptionists at the front desk had to explain the process of streaming and triage to patients. The department had different coloured chairs for triage and streaming. However, patients were unaware of this and sat wherever and waited for their name to be called. Triage patients we followed were seen relatively quickly in one of the triage rooms in operation. Initial observations, recorded on the electronic record, and tests were performed and then appropriate patients were returned to the waiting room to await being seen by a clinician. Children were sent through to the paediatrics waiting area following triage. Before this time, they waited in a sometimes very busy noisy waiting room. The waiting room was monitored by the clinicians in the triage rooms. However, this only included a cursory glance at those waiting to identify if anyone had deteriorated. Wristbands, with patients details on, were not applied at this point despite medication being given and a potential risk of deterioration whilst waiting. We were told that patients should be reviewed 2 hourly whilst in the waiting room. However, we did not see or hear of this occurring whilst we were on site.

Patients were called by clinicians from the waiting room to the appropriate area for assessment and treatment. We saw a mixture of paper and electronic records in place for patients. On paper records we noted that risk assessments were completed but national early warning scores (NEWS) 2 scores were not generated. Staff appeared to be used to the dual system of recording patient information. A member of staff in majors was designated to monitoring that all patients had their observations undertaken every 3 hours. This nurse checks with the nurse looking after the patient that observations, usually hourly in majors, had been undertaken. Whilst this was documented in a separate paper booklet, we did not see any safety rounding documentation in the patients notes. Audits demonstrated that falls prevention assessment was undertaken within the resuscitation and main areas of ED. Compliance in December 2025 was between 80 and 100%. The completion of the Waterlow (pressure area) assessment was low in December 2025 at between 60 and 67%. However, improvement to 100% was seen in January 2026. Ambulance handovers were completed on arrival or shortly after. These were detailed and information was relevant to the patient.

There were well known pathways of care for specific patients such as trauma patients requiring secondary transfer, patients who required neurosurgery, patients with burns and severely ill children would all be transferred to different hospitals. There were good communications systems in place to ensure a robust handover was given and patients received timely care on arrival. Staff reported good working relationships with the hospitals that they regularly transferred patients too.

The department had a clear pathway for patients with mental health needs. When people with mental health needs arrived in the department, triage nurses completed an initial assessment. They referred the patient to a third-party mental health trust who could stream patients with mental health needs directly to other services, through a pathfinder role. The team undertook assessments in parallel, not waiting until a patient had been medically cleared to start assessments.

The department had a mental health assessment unit. This was provided by a third-party provider, but the patients in the unit remained ED patients. The unit had five bays and was staffed by mental health nurses and support workers 24/7. However, we heard that the third-party provider planned to shut the unit at the end of March 2026. The unit had clear criteria to guide which patients could use the unit.

Mental health trained security staff supported clinical staff when there was a risk of violence and aggression. Staff completed a risk assessment form, that detailed the legal framework and rationale, prior to restraining a patient. If a patient went missing the security team would undertake an approved search. There was a debrief following any restraint to which all staff involved were invited.

The trust had a substance misuse team. This service was available between 8am to 8pm Monday to Friday, but the trust was looking to extend this to cover the weekends. The team visited the ED daily to identify patients who they can support. They encouraged the championing of their service through the nurses working in the emergency department. Staff who advise, treat and see patients with mental health issues or dementia in-reach into the emergency department daily. The department had a process for supporting people subject to section 136 of the Mental Health Act.

The paediatric ED was supported to care for patients with a mental health need by the Children and Adolescent Mental health Service (CAMHS) team provided by a third-party provider. Staff told us that they often waited for CAMHS members of staff to attend the department and complete assessments. This was due to the workload of this service. However, the play specialist assisted to reassure and listen to patients who were in the mental health suite in the children’s emergency department. The trust had reviewed its pathway for 16- and 17-year-olds, who now attend the adult ED. The psychiatric liaison team responded to most emergency referrals within one hour.

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

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

Staff had training on how to recognise and report abuse, and they knew how to apply it. Data provided to us by the trust showed that compliance with all safeguarding training modules apart from safeguarding children level 1 were over the trusts target of 90% within the nursing staff. Whilst safeguarding children level 1 training did not meet the target; level 2 training was above the target set by the trust. This meant that staff receiving level 2 training would have covered the areas in level 1 training. Medical staff did not meet the target for any safeguarding training with children’s safeguarding being particularly low. Doctors completing safeguarding adults training level 3 was 78% compliant with children’s safeguarding at 58%. The lead clinician had plans to address this concern.

We observed the triage of a child attending with burn injuries. The patient’s mother was treated with kindness, compassion and dignity. Safeguarding concerns were highlighted because of the nature of the injury. The nursing staff demonstrated sensitive questioning of how the accident had happened and what actions the mother had taken before deciding if there was a safeguarding risk. In this instance the mother was able to describe how this accident had occurred and had taken appropriate and effective action to minimise the extent of the burn. Staff displayed a good understanding of the need for safeguarding referrals and were not going to complete a referral in this case due to the immediate actions of the mother. However, they were able to describe circumstances where a referral had been made.

Staff had access to safeguarding policies, which referenced appropriate legislation and best practice guidance. Safeguarding information was displayed throughout the department. Staff told us they were confident in raising safeguarding concerns and the process for referrals on the electronic patient record system and was easy to complete. Staff were able to tell us when they recently completed referrals. Staff told us there were safeguarding link nurses within the department who provided support and advice when needed.

The service shared concerns quickly and appropriately. Staff told us that Deprivation of Liberty Safeguards (DoLS) were not used within the ED, where applicable doctors completed Mental Capacity Assessments (MCA) for best interest’s restrictions. The trust had delivered training courses on the Mental Capacity Act and DoLS, staff told us that they found the training helpful. The service had also arranged access to the Oliver MacGowan training which staff found very helpful in meeting people’s needs. Oliver McGowan training is on learning disability and autism. Staff considered patient’s capacity when assessing them. Staff recorded an assessment of capacity in one of the records we reviewed.

Staff provided care to meet people’s needs that was supportive and enabled people to do the things that mattered to them.

The department had effective processes and tools for assessing patients when they first presented to the department and monitored patients for signs of deterioration when they were taken into the main department. Patients we spoke with told us their wait for triage had been timely. Patients were triaged by trained triage nurses. Patients had their basic observations undertaken, National Early Warning Scores (NEWS) undertaken and any relevant tests were ordered. However, despite processes being in place to monitor the waiting room we did not see this occurring. The average wait for patients arriving by ambulance in January 2026 was just over 23 minutes. This was better than many trusts in the area.

Leaders and staff could articulate what risk assessments they used to keep patients safe. Security staff were trained in least restrictive restraint. Restrictive restraint was only used as a last resort and was monitored by leaders. We noted one episode where rapid tranquilisation was required. Staff had not completed post-intramuscular rapid tranquilisation physical health observations for this patient for 4 hours. This incident was being investigated after we highlighted this. The trust had updated its rapid tranquilisation policy last year and is in the process of auditing currently.

Patients told us they felt safe and supported whilst they were in the ED. They could approach staff if they felt their health was deteriorating and they were confident staff would respond to their concerns. We saw posters about Martha’s rule, a programme which enabled friends, relatives and patients themselves to make a direct referral to the outreach team if they felt the clinical condition of an adult or child patient was actively deteriorating. However, staff felt that this route was rarely used as family and friends would approach staff within the department first.

Staff we spoke with described the processes to assess and identify patients at risk and how they assessed and documented mental capacity. Staff had a person-centred approach and involved patients, where possible when completing risk assessments. During December 2025, the service monitored compliance with completion of the sepsis documentation. This demonstrated that different areas of the department were completing this at different rates. Compliance with documentation of the sepsis screening tool ranged from 40% to 75%. The level of compliance fluctuated widely in the department. Over the five-month period from September 2025 to January 2026 the average compliant rate was around 70%. We saw information in staff rooms about completing the sepsis documentation.

The service had a frailty team who worked with the department. The frailty service assisted patients to return to their homes as soon as possible by supporting patients to be at home. ED either referred patients to the frailty team or the frailty team in reached into the department to ensure that patients who met the criteria could access this service.

The department had a nursing notes booklet for patients with mental health needs. This booklet contained a range of sections, including on mental state and description, a mental health risk assessment, mental capacity assessment, enhanced observation recording, NEWS, clinical institute withdrawal assessment and post dose rapid tranquilisation. Partners, such as psychiatric liaison reported they worked well with department staff. Several members of staff commented on the positive culture and working cohesively to ensure the patient was kept at the centre. However, staff highlighted that the rates of patients leaving the department had increased. They felt this was due to the amount of time people waited to access a mental health bed.

The equipment and facilities, in the main department, supported the delivery of safe care.

Patients told us they were well looked after by staff, despite long waits, crowded waiting rooms and cubicles being doubled up to care for 2 patients. There was a separate area for children and their families which was safe and secure and there were toys to keep children occupied and a play specialist who helped patients and families to remain calm and reduce stress

Computers were widely available throughout the department which meant that staff did not have to wait to access them. However, we observed several unlocked and unattended computers displaying confidential patient information on the inspection. We escalated this to leaders whilst on site. They took immediate action to remind staff to remove their access cards when not using the computers. White boards displayed where patients were within the department and had some information about the patients. Whilst these were predominantly for staff other patients and visitors could read these.

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

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

The department had a resuscitation area which had capacity for 4 patients, including an area to treat children. Each bay had 2 trolleys in it to allow for an extended number of patients in the resuscitation area. Whilst the original bay was large enough to easily allow for a multi-professional team to care for and treat the patient, this was restricted when 2 patients used the same bay. The bay reserved for children was seen to have a large amount of equipment temporarily stored in it. However, we saw that this was quickly removed when a child was expected into the area.

Equipment, facilities, and technology supported the delivery of safe care. Each treatment area had standardised equipment. Standardisation of equipment aims to reduce the risk of harm to patients because staff who work between these areas will have greater familiarity with a smaller number of devices, thereby reducing the risk of error. Resuscitation trolleys were secure and checked regularly. We reviewed three trolleys and found that they had been appropriately checked, and this was recorded.

The department was split into defined areas each colour coded. The green area had cubicles which had been split using curtains into 2 bedded areas. There were mixed sex patients in each of these cubicles. There were numerous areas where extra areas had been created to see and treat patients. Curtains were often used to provide some sort of privacy screening but the effectiveness of this was not always robust. There was a policy on using escalation spaces which included where to use, how to care for patients in these areas. The department was not using escalation spaces during the inspection. In March 2026 NHS England requested that these temporary spaces were renamed Corridor Care. However, we did not see patients being cared for int he corridor on our inspection.

The department regularly used 2 rooms for supporting people with mental health needs. These rooms were at the end of a corridor and in a quieter area of the major’s department. The rooms both had 2 doors that could open outwards, had strip alarms, did not contain any obvious ligature anchor points, had CCTV cameras and contained heavy furniture. They had lighting panels that could light the rooms in different colours.

The rooms had a connecting door, acting as the second door for 1of the rooms. This had a glass viewing panel that could not be closed. This meant that there was no privacy in the rooms. Psychiatric Liaison Accreditation Network (PLAN) standards (p.14) notes that rooms should “Have an observation panel or window which allows staff from outside the room to check on the patient or staff member, but which still provides a sufficient degree of privacy.” In 1 room, the second door opened onto the corridor. This was kept locked unless needed. Both rooms had heavy couches. These were badly damaged and dirty, with multiple rips. Following our raising of these issues the trust sent us an action plan detailing that they had addressed the issues of privacy between patients and had ordered new couches for the rooms. People in the mental health rooms used the shower / toilet in the blue area. This room did not have anti-ligature fittings and contained potential ligature anchor points. The matron told us that staff would either wait outside the room or wait inside the room depending on the risk of the person. Ligature cutters were in the resus trolleys.

The paediatric emergency department had one room for supporting children and young people with mental health needs. The room had 2 doors. One opened into the adult area. This was kept locked unless needed. The room had trolleys previously. These had been replaced with a heavy bed, heavy armchair and safety pod. The door to the paediatric department had viewing panels and could open outwards. The room had some potential ligature anchor points, including the push alarm. The matron told us that they had funding to make the changes to the room, but the work had been delayed. The mental health head of nursing told us that staff would assess the needs of patients before placing them in the room. They could use a ligature free room on the paediatric ward if needed.

The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development.

The service had enough nursing staff to keep patients safe, and the nursing staff matched the planned numbers on the day. Skill mix was reviewed regularly and adjusted throughout the day. The department had 15 emergency consultants, of which 3 were part time. There was consultant cover in the department from 8am to 10pm 7 days per week which was followed by on call arrangements. This was below the national guidance recommended levels of consultant cover. Leaders understood this hot spot which demonstrated that a further 9 consultants were required and plans were in place. The service used regular locum doctors. The children's department was covered with doctors and nurses with the appropriate paediatric competencies. Cover was provided within the department from 8am to 5pm by a consultant and mid-grade. After this time the mid-grade doctor had access to the consultants in the main ED. During the nighttime was provided by a mid-grade ED doctor but the paediatric ward doctors generally based themselves in the ED overnight when the ward was quiet. There were 2 doctors with the Paediatric Emergency Medicine qualification who worked in the department. Most nurses had a qualification in paediatrics life support (86%) there were 3 nurses who were not currently up to date with this training. If children were due to stay for any length of time they were transferred to Hippo ward. Two paediatrics nurses were on duty at any one time. They were supported by a senior nurse during the day.

Staffing was flexed to meet the needs of the patients attending the different areas of the department. Huddles occurred regularly throughout the 24-hour period to review the needs of patients in the department. All staff felt that they had good access to training. This was encouraged through the mobile messaging service as a defined area of support.

There were robust and safe recruitment practices to make sure that all staff, including agency staff and volunteers, were suitably experienced, competent, and able to carry out their role. There was a suite of policies relating to safe recruitment and all new starters received a comprehensive induction. The department had a dedicated senior pharmacist and senior pharmacy technician in the department to help in reach into the department to review and flag for further review. This service was available 5 days a week. Medicines were reconciled during their time in the department.

The service used bank staff when necessary and regular agency staff, and ensured they were familiar with local systems and processes. We spoke with agency and bank staff who stated that they were regularly employed by the department and as such felt part of the team. They were included in secure information channels so that they received information like the trust staff. These staff were aware of the issues we raised with them such as actions following complaints etc.

Leaders told us that there was good team culture within the department, that across the professions there was good training opportunities and multiprofessional relationships. We were told there was a culture of supporting staff to develop and progress. In 2022 the department had a vacancy rate of 40% but this had decreased to 15% for nursing staff and nearly 5% for medical staff by 2026. This was above the 10% target for nursing staff. The turnover rate for nursing staff over the 12-month period was 9.7% and 16.8% for medical staff. Whilst overall sickness rates were 6.7% the main cause of sickness was anxiety, stress and depression for nursing staff and coughs/colds and pregnancy for medical staff. All newly qualified nursing staff underwent a preceptorship programme which lasted 18 to 24 months. This was followed by undertaking a recognised course in nursing within the ED

During the assessment, the department was busy with more patients being cared for than the department was built for. This put inevitable pressure on staff. However, staff said they felt able to respond to increasing demand as staff supported one another well. We observed staff who were busy but upbeat and smiling. They could highlight the issues they faced but were resilient to these because of the support they received from leaders and other staff. Staff told us there was support and mutual respect among staff working in the department. We observed effective and cohesive teamwork. There was a culture of just “one team” and shared responsibility. We attended both nursing and medical handovers and found that the patients in the department were discussed along with ongoing plans for treatment and care. At the huddle in the middle of the day, we saw and heard cohesive working where medical staff prioritised patients nursing staff were concerned about.

Staff received mandatory training appropriate and relevant to their role. Overall compliance for adult nursing staff was 90%, and 73% for medical staff. The trusts target for training compliance was 90%. However, elements of training that were lower than the target included basic life support and moving and handling training. Most medical and nursing staff had a higher level of training than basic life support. There were actions in place to address areas of non-compliance.

The service had a process for carrying out effective appraisals, 99% of nursing staff had received an appraisal and 100% of medical staff had received an appraisal. Both were better than the trust target of 90%.

Medical staff were supported by named supervisors. Resident doctors had protected time for teaching. Feedback from resident doctors was positive, they felt supported and invested in to develop and gain new skills.

Staff told us specialised mental health training was available to staff. Whilst mandatory training for nursing staff in issues relating to mental health training were above the trusts target for nursing staff and below it for medical staff. This included conflict resolution nursing staff 99% and 100% for doctors, Mental Capacity Act and Best Interest training 96% and 78% respectively, and restraint training 97% and 77% respectively. The senior medical team were aware of the shortfall in their team and had action plans in place to address this. All ED members of staff attended a day training course on mental health. This day includes sessions on mental health awareness, the mental health liaison team, conflict resolution, management of agitated patients, substance misuse and the application of the Mental Health Act in ED.

The trust rostered 2 mental health nurses on all shifts currently. At the time of the assessment, these were bank and agency members of staff. The trust was expanding its specialist mental health staffing. It had a mental health head of nursing and a band 4 mental health wellbeing practitioner role. It had recruited a mental health matron recently and was recruiting registered mental health nurses and mental health wellbeing practitioners. Once these staff had been recruited, they planned to have permanent registered nurses and mental health wellbeing practitioners on all shifts in ED.

The trust had funding for a capital nurse to develop their approach on enhanced therapeutic observation care (ETOC). They were looking to develop training for staff in how to improve the training offer. There were 4 mental health leads within the ED: bespoke mental health lead, matron mental health lead, consultant mental health lead, and clinical fellow mental health lead.

The service did not always assess or manage the risk of infection. They did not always mitigate and control the risk of spreading infections through good hand hygiene and appropriate preventative actions, such as staff being bare below the elbow.

During the assessment we observed staff within the service did not always wash their hands in line with infection control policies and adhere to the uniform policy set out within the service. We observed that some staff had false nails, nail polish and jewelled rings on their fingers. This did not comply with the ‘bare arms below the elbows’ policy, in accordance with National Institute for Health and Care Excellence (NICE) guidance. Following our inspection, we received an action plan from the trust which stated that they have reiterated and trained staff on infection control principles. The trust sent a newsletter to all staff reminding them of the principles of hand hygiene. Personal protective equipment and handwashing facilities were readily available. However, we also noted that gloves were not always changed appropriately and staff looking through multiuse patient equipment trolleys whilst wearing gloves. The risk from these practices is that infections could be spread between patients due to ineffective handwashing and mis use of personal protective equipment.

The service had an infection prevention and control policy, which staff were aware of, and which set out key information for staff to support maintaining infection, prevention and control standards 91% of nursing staff and 81% of medical staff were up to date with their training in infection prevention and control. Hand hygiene, local cleaning and infection prevention and control audits were undertaken by the service. The hand hygiene audit from November 2025 demonstrated that compliance was rated at 92%. The environmental audit in February 2026 equally scored 92% compliance.

Domestic staff were visible within the department. We observed both clinical staff and the cleaning staff diligently cleaning equipment and the environment. We saw ‘I am clean’ stickers placed on surfaces that had been cleaned. The floors were clean despite heavy foot traffic and the constant movement of people and equipment. The cleaning schedule set out by the service was followed. We saw disposable curtains labelled with the date they were last changed. Cleaning records we saw were up to date and demonstrated all areas and equipment were cleaned regularly. Clinical waste was disposed of safely.

Clinical areas we saw were clean and had suitable furnishings which were mostly clean and well-maintained. During the inspection we informed the senior team that the sofa’s in the mental health cubicles were ripped and stained. The damage prevented effective cleaning of the surfaces. The trust sent us an action plan which outlined that they had ordered new couches for these rooms.

A single negative pressure isolation room was available in the green area of the department, and a large tent was available outside of the service for any incidents requiring decontamination. The consultant we spoke with told us that they had had chemical, biological, radiological, and nuclear defence (CBRN) training about a year ago along with some nursing staff and other doctors.

Medicines were kept secure and were only accessible by authorised staff. We saw improvements had been made around medicines management since the previous inspection.

Medicines were generally administered as prescribed. Staff had access to local and national electronic records. In records we reviewed, time critical medicines were given in a timely way. Patient records were flagged on admission to show if they needed time critical medicines or had complex needs. Where doses were missed due to medicine unavailability, they were highlighted in monthly reviews which was fed back to matrons and leaders in the areas to be discussed with nursing staff.

We heard that pain relief was not always timely when people arrived in the department. However, we saw pain relief being given to a patient in the waiting room. Whilst this addressed their pain, it was not done in line with the administration of medicines policy as the patient did not have a wrist band on. As patients moved through the department pain relief was given in line with the policy as a wrist band was applied and staff checked that patients were not in pain. Documentation audits demonstrated that patients received pain relief but that this was not always recorded as being assessed as to its effectiveness.

The service was part of a pan London pilot in collaboration with other hospitals and an ambulance service to improve support of people with time critical medicines. Work was ongoing, having just completed the data collection phase.

Whilst the clinical pharmacy service delivered to the ED was not in line with Royal College of Emergency Medicines (RCEM) guidance, the service used a prioritisation process for identifying and reviewing high risk patients. They had a dedicated senior pharmacist and new senior pharmacy technician in the department to help in reach into the department to review and flag for further review. However, this support was limited at weekends. Staff told us that the department was regularly supported by pharmacy staff from other areas. The service used a cluster model where there were twice daily briefings to discuss new admissions and urgent and complex cases. We saw good practice where pharmacist support was embedded in post-take rounds with other members of the multi-disciplinary team (MDT). Staff told us they were able to provide advice and interventions at the time of treatment planning in new patients attending the service.

Staff in the children’s ED had ad hoc support from dedicated paediatric pharmacists. Staff told us that support was accessible if they needed it.

There was a process for supplying medicines on discharge from the department. Medicines were transferred with patients admitted to an inpatient bed, and the record system allowed medicines previously ordered to be sent to where the patient now was.

Staff received regular medicines training and the pharmacy team worked closely with practice development nurses to support staff in each area.

The service had a governance process in place to review incidents that occurred within the department. The service produced quarterly medication safety reports and newsletters to share learning. There was regular monthly walk round audits of medicines management and controlled drugs in different areas of the department.

The service had ongoing improvement projects to medicine safety. For example, we saw examples of improvements made around improving safety when prescribing paracetamol. The service had also identified gaps in pharmacy interventions for mental health patients in the department and had started a programme to improve this.

The service had a process for receiving and actioning patient safety alerts.