Warwick 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 good. At this inspection the rating has changed to requires improvement.

We looked for evidence that people were protected from abuse and avoidable harm.

We rated safe as requires improvement. We assessed eight quality statements. There was not always a positive learning safety culture and staff did not always receive learning. Staff were open and honest when things went wrong or could be a risk, but action was not always taken to address concerns raised. Staff did not always provide safe care and treatment, including understanding and managing risks, and not all staff showed professional curiosity in safeguarding. The environment was not always fit for purpose and did not always meet people’s needs. Leaders had increased staffing levels, however there were not always enough appropriately skilled and experienced staff to meet the needs of children and young people. Staff received some training and appraisals to support staff were not always completed.

The service managed the risk of infection, and systems for appropriate and safe handling of medicines were used.

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.

Staff reported most incidents, but they did not always see actions taken as a result. Whilst lessons were learnt some staff were not aware of recent learning and some staff reported action was not taken in a timely way.

Staff understood and felt able to raise concerns, however not all staff reported incidents. We spoke to 3 members of staff in paediatric ED who all said they did not always report incidents. They told us an incident report was always completed when a safeguarding referral was made but for near misses, staffing issues and times when children couldn’t be accommodated in a cubicle or away from adult patients in distress was not reported.

There were systems to monitor and respond to incidents, compliments and complaints, however they were not robust, and we did not always see evidence of how themes were addressed.

For example, staff raised the need for a piece of equipment to show children's veins, highlighting its importance in January 2024. They felt it was not approved until an incident happened 3 months later, where staff had to go to the children’s unit to borrow the equipment during an emergency. Trust leaders said they were waiting for charitable funds to procure the equipment. The most recent staff survey showed a good reporting culture.

Learning was not routinely shared across the department. Staff could not describe recent incident learning or sharing from clinical governance meetings.We spoke with 8 staff members who could not describe any incidents that occurred in the department or learning from incidents that had been shared.

We raised our concerns with the trust about the identification of key risks. Actions the trust took in response included reinforcing the incident reporting process trust wide and sharing the messaging in huddles amongst others.

Safety matters were regularly discussed at monthly directorate meetings, which included responding to external safety issues, like guidelines, safety alerts and audits.

From 1 September 2024 to 27 March 2025, the top 3 incident themes in the ED were skin damage, medication and ambulance transport issues. Skin damage was the most reported incident, and the trust told us there was limited learning for ED as the incident reporting was for pressure damage that occurred outside of the trust which enabled learning for primary care stakeholders. When we reviewed patient records, none out of 7 adult patients had documented skin assessments despite waits in the department of over 16 hours.Some incidents will have occurred when the patient was cared for in a different service but are reported on admission by the trust.

Learning was identified but was not systematically disseminated. We reviewed the patient safety report for the emergency division for October, November and December 2024 and January and February 2025. We saw that updates and actions were monitored by the division where incidents were reported with moderate harm or above and that deaths in the department were identified and discussed as part of the mortality dashboard. In these meetings, trust wide lessons learned were shared every month. However, learning was not disseminated from meetings to staff in the department.

We reviewed 2 patient safety incident investigations (PSII) Actions and learning were identified in both reports.

There was a directorate wide compliments and complaints newsletter. Newsletters from March and April 2025 reflected themes were shared over time, so staff could see how they had changed. The main reasons for complaints related to clinical care and treatment, staff attitude, behaviour and values, waiting times and disagreeing with diagnosis. There were 8 open complaints during the assessment window.

There were systems for continuity of care when patients moved between services in the hospital. However, they were not always timely due to hospital wide capacity challenges. There were structured handovers between staff and wards, however we identified some gaps in completion. Patients were not always monitored for deterioration in line with the trust policy. Safety performance was not monitored at department level, and we did not see evidence of actions to address poorer performance in the department.

There were different pathways to enable patients to be seen by the right person, in the right place, at the right time. Some of these pathways worked well.

The emergency department (ED) had a clinical decision unit (CDU) with 5 chairs that could be used as a "fit to sit" are at times of escalation.

There was an ambulatory emergency care service in the hospital which meant patients who needed short term treatment could be managed without admission to hospital. There was an Advanced Nurse Practitioner (ANP) each shift who would review the ED list and arrange to see patients that met their criteria.

There was a pathway for frailty and staff from the frailty team came to the ED to actively support with discharge and transport to social care services when patients were in the ED for more than 24 hours. This reduced the risk of further deterioration from long stays in the department.

There were pathways for patients to move to other specialities, however capacity challenges meant that patients could not always follow them in a timely way, some patients waited over 23 hours in the department.

The ED electronic patient record (EPR) system was not accessible by clinicians elsewhere within the hospital, so discharge summaries were printed and travelled with patients when they left the department with plans to move to a hospital wide EPR in the next year.

Clinicians in the ED could refer patients to step up care through virtual wards, which meant that patients could receive consultant led care from home as an alternative to hospital admission.

There was a mental health risk assessment tool which supported staff to identify the level of risk in adults so they could ensure they received the right pathway of care.

Mental health partners did not have access to electronic patient records. They received a short paragraph explaining the referral, but they told us it was not always a useful summary.

There were increasing numbers of children and young people presenting at ED with mental health issues or crises. Specialist paediatric nurses liaised with the community mental health team to ensure children were safeguarded and put in social care placements when possible.

There were pathways to transfer children and young people to the paediatric ward or assessment unit, however staff told us transfers were not always easy to coordinate because there were often not enough paediatric competent staff in the department. The service had addressed the competencies of staff working with children after the inspection which should increase the availability of competent staff to coordinate transfers and see and treat children and young people in the department.

Staff told us they were developing links between the paediatric nurses in ED and senior nurses on the paediatric assessment unit and paediatric ward to share information particularly around beds and flow, but this was not yet fully embedded.

There were structured handover documents for nursing staff and medical staff. We reviewed the handover documents for 26, 27 and 28 March 2025 and found they were mostly completed in line with the process outlined, however we identified 5 gaps in controlled drugs nurse in charge checks which had not been signed.

The trust had an internal and external escalation policy and associated action cards that detailed steps to take when demand on the hospital increased. The Emergency Management System (EMS) used was system wide and developed by the ICB to manage capacity and demand, and the trust updated their position in line with guidance.

The paediatric ED used a paediatric early warning system (PEWS) to record patient’s clinical observations. We reviewed 10 sets of observations, and the PEWS score had been completed correctly. We reviewed audits and found 100% of children and young people had their baseline observation and pain score recorded on arrival, however 0% of children who scored 5 or above had their observations rechecked within 30 minutes, which was not line with guidance.

The service did not audit adult observations monthly, in line with their “Identification and Management of the Acutely ill Patient (incorporating NEWS2)” guideline. A quarterly NEWS2 audit for ED in March 2025 showed 100% of patients had baseline observations recorded on arrival however, only 40% had repeat observations recorded in line with their score and 90% had observations recorded within 60 minutes of being transferred out of majors.

Patients did not always receive repeat observations in line with the local process followed during our inspection. We reviewed 7 adult patient records: Six out of 7 patients did not receive observations hourly in the waiting room. One of the patients had their observations completed 3 times in 9 hours. This posed a risk because patients could deteriorate without the appropriate intervention. After the inspection, the trust developed a standard operating procedure for the waiting room and amended the timescale for repeat observations to fall in line with national guidance.

Nationally required data was recorded in patient records, and we saw records were detailed, however audits were not provided. The service audited patient records through the patient care indicator (PCI) audit. We asked the trust for their most recent records audit, and they did not provide it. They did submit weekly performance against the Emergency Care Data Set (ECDS) between 21 April 2024 and 30 March 2025, which showed 31 out of 33 areas met the standard.The ECDS is a national data set used in England to collect information about urgent and emergency care.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Adult safeguarding processes worked well, and registered children’s nurses understood their professional responsibilities. However, not all processes supported adult registered nurses to safeguard children and young people, not all staff had received training in safeguarding, and staff triaging paediatric patients did not always complete assessments of social and family situations. Not all staff were clear on the processes for mental health assessments.

There were clear systems and processes for referring concerns about safeguarding children. All the paediatric staff and nursing associates we spoke with knew how to refer a safeguarding. Staff gave recent examples of safeguarding concerns they had raised and told us they nearly always received feedback about safeguarding referrals they had made.

Staff felt well supported by the hospital safeguarding team, they knew how to contact them and could request practical advice and support. Staff in the paediatric ED told us incidents were always reported when a safeguarding was raised, and they were confident in following this process.

Safeguarding was a standing agenda item at the “paediatric AE liaison meeting”, however this was scheduled every 6 months, and when we looked at the most recent minutes from November 2024, the only item discussed was level 3 training being available. Safeguarding multi-agency meetings were attended by the trust safeguarding team and key information and learning was shared with the ED team.

The trust had a safeguarding children and a safeguarding adult’s policy. Both policies had sections relating to safeguarding training. They signposted to intercollegiate frameworks or were determined by individually assigned training levels. However, when we asked the trust about specific competencies for adult nurses who worked in the paediatric department, they said relevant staff had this training but did not provide evidence staff had appropriate level safeguarding training to see and treat children and young people in line with the policy and national guidance.

Not all staff had completed safeguarding training, and it was unclear if staff who needed level 3 safeguarding children training had completed it. Only 51.7% of medical and dental staff had completed safeguarding training. Overall, safeguarding level 2 compliance was 87.8% and safeguarding level 3 compliance was 72.2%. The trust did not provide their target for safeguarding training, so we could not determine if staff groups met the target.

The trust later provided safeguarding training compliance figures; in May 2025, 89% of nursing and 75% of medical staff had completed safeguarding training.

The electronic triage record had a safeguarding alert which flagged known safeguarding concerns to staff and a safeguarding field which was mandatory, and evidence reflected this process was followed for adults.

However, adult nurses did not always keep children safe through safeguarding. Paediatric Staff told us that if children were triaged by adult nurses, the safeguarding social history field was often not completed and therefore, a thorough assessment of risk to the child may not have been completed. Staff said they raised these concerns to leaders but had not received a response.

Further, we observed a case where an infant was triaged by an adult triage nurse. The nurse did not obtain a social history, or explore how the injury was sustained, they did not ask any further questions before allocating to the GP area.

Staff told us they did not recall what training they had received to complete an initial assessment in children. All staff who triaged patients had completed training for the use of the Manchester Triage System which includes the triage of children.

We raised our concerns with the trust who provided information about actions they had taken to address our concerns. They told us that all nurses who work in paediatrics or triage had relevant level 3 safeguarding training however, upon request, corroborating evidence was not provided at the time. Following our assessment the trust provided information that showed staff had been trained to the appropriate safeguarding level. The trust also told us the safeguarding team were running professional curiosity training to remind staff of their professional responsibilities, and the patient record system was being updated so that clinicians could positively confirm parental responsibility. Daily huddles for medical and nursing staff included learning for 2 weeks following the trust becoming aware of the concerns we raised.

Leaders told us all triage nurses had done mental health risk assessment training, however one triage nurse could not articulate specific mental health training they had completed including criteria for when an assessment should be carried out. We observed mental health risk assessments as part of the triage process and only 2 out of 4 patients who should have had a risk assessment did.

Patients with mental health concerns were risk assessed and may be cared for in the waiting area. Mental health partners told us that they did not feel this was always appropriate. The dedicated mental health room was rarely available and often staff used the relative’s room, which was not appropriate for their needs. For example, it did not have call bells or alarm systems in place.

The service did not always work with people to understand and manage risks using the systems available. They 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. Triage processes were in line with national standards however streaming was not always completed by a suitably qualified and experienced staff member, initial assessment in children and young people was not always robust. Risk assessments were not always completed in line with trust processes and there was limited oversight of the waiting area when patients were in the department for a long time. The service addressed urgent concerns we raised and put mitigating actions to reduce the risk to patients.

There was a comprehensive triage process using a nationally recognised triage model. The process for adults was well embedded and robust. We observed patients were reassured throughout the triage process and their pain was monitored.

National guidance for EDs states "patients arriving in the department should be assessed promptly by locally agreed processes within 15 minutes of arrival". The service met this target every month since January 2020, where patients were booked into the main ED. In January 2025, the service ranked 15th out of 117 ED services.

Patients were given a wristband when they booked in which was good practice because they could be identified throughout their journey. This was important when patients were moved around the department and the hospital.

Patients who arrived in the ED reception were routinely streamed to minor injuries using a pre-defined list of illnesses and injuries, by receptionists, without any clinical assessment or clinical review, including paediatric patients. Reception staff we spoke with did not have the competency or training to stream patients away from the main emergency department.

Patients streamed to the minor injuries unit, including children, did not receive a clinical triage in minors if they had a presenting complaint on the pre-defined list. If the wait in minors was not long, patients could be seen within the 15-minute initial assessment time, however this was not always the case, and we saw patients who attended waiting up to 45 minutes to be seen.

We were concerned about the oversight and management of the waiting area for patients who waited in the department for long periods of time.

We observed the waiting room, once in the afternoon and once at night, and saw no evidence of registered staff observing patients in the waiting area, including patients who had IV fluids administered and children.We were told a nurse had been allocated, but the trust did not provide evidence of this.

We asked how patients were determined as appropriate for the waiting area, and we were told this was based on clinical decision making by the nurse in triage, or the nurse in charge.

There was a risk that patients were not regularly monitored in line with their condition and could deteriorate in the waiting room. Clinical support workers allocated to the waiting room felt there was a lot of responsibility on them to manage the waiting area, observations and attending patients. Patients waited for a long time in the waiting room with limited review, for example one patient was in the waiting room around 24 hours and in that time only had food and fluid documented once and 4 sets of observations documented, which was not in line with the trust’s policy. Another patient was left in obvious distress and in pain in the waiting room while they waited for triage. They had no analgesia given for 36 minutes from arrival to administration. However, the trust scored better than the England average in the CQC Urgent and Emergency Care Survey for the question if staff helped patients to control their pain.

Risk assessments and observations were not completed in a timely way, in both the waiting area and the main department. We reviewed 7 adult patient records:6 out of 7 patient records we reviewed did not receive observations hourly in the waiting room, or did not have the emergency checklist completed in a timely way which was the system at the time of the inspection. None of the 7 adult patients we reviewed had documented skin assessments despite waits in the department of over 16 hours.There was a risk of harm to patients who could deteriorate, especially during long waiting times, including deteriorating of skin integrity.

We reviewed the records of a patient who had not had assessments completed in line with the policy. The emergency department checklist was not completed in line with the policy and the patient record had no documentation about capacity assessment, or if that had been considered. There was conflicting information in the patient record about the capability of the patient to take medicines and their capacity. The patient record did not reflect that care was provided in a way that met patient needs or involved the patient in managing their own risk.

We raised our concerns with the trust,and they stopped administrative staff streaming patients and implemented triaging of all patients by a triage trained registered nurse, allocated a named registered nurse for the waiting room and wrote and circulated a new SOP for the ED waiting room which included actions to be taken if, children were waiting in the main waiting room

The safety round was a tool used by shift leaders to maintain oversight of the department, including patient risk. Data provided by the trust showed gaps in completion during March 2025. Senior nurses completed safety rounds across all bedded areas in the department and the fit to sit area and included checking patient observations were taken and acted on in line with policy, risk assessments completed, medicines were appropriately prescribed, and infection prevention and control measures were followed. We reviewed the safety round data from 4 March to 3 April 2025. The safety round was not consistently completed in every area for all times of day. We saw on some days, the round was completed in each area morning, afternoon and night, and on other days, areas were checked once across the full 24-hour period. No safety round was recorded on 12 days in March 2025, and we saw examples of safety rounds completed inconsistently throughout the day, for example, on 8 different days in March 2025, each area was checked on the night, but there were no checks throughout the day..

We reviewed the outcomes of the safety rounds and found, for those completed, 88.7% of patients had their observations or NEWS2 completed within the last hour, and 90% of patients who needed neurological observations were up to date, 84% of patients had a pressure ulcer risk assessment completed and 25% of patients reviewed were a falls risk and escalated to the nurse in charge for potential movement to a higher visibility area. However, because there were gaps in the safety round data, we were not assured when the department was under pressure, there was sufficient oversight of patient checks and risk assessments.

The department used a robust mental health risk assessment used. Staff could explain how it worked, and it was completed correctly in records.

Children were usually triaged by adult nurses, trained in triage. Staff we spoke with told us they did not feel they had the skills or training to safely triage children. The paediatric ED team were concerned that children were not always streamed appropriately by triage. They gave examples of children streamed to the GP service who needed further interventions. For example, if a child needed observations or bloods taken, they would be brought to the ED paediatric team, however, staff told us that the child still showed as under the care of the GP, so oversight of their care was unclear.

The triage SOP and systems for streaming children to the GP service, provided assurance that there were processes for children. However, this did not address oversight of children when they moved around the department or that staff did not always have clarity about who had overall responsibility for the child.

Staff told us about examples where there were missed opportunities to escalate potential risk and near misses in the department relating to paediatric patients, where registered children’s nurses, or staff with paediatric competencies had not been involved in their care.

The department was often crowded, with patients receiving treatments in the waiting room. The waiting room did not have enough capacity for the number of patients in the department, and there was not enough space in the paediatric waiting room for the number of children that attended. The distance from the ED to the CT scanner was too far and plans to address this were limited to one funding bid. There were not appropriate facilities for assessing adults or children with mental health needs, and the department did not meet nationally recognised standards.

People were kept safe while waiting to be seen or receive treatment. The department did not care for patients in corridors, which was good practice. The facilities were well maintained, and any equipment used with patients was in good working order and used safely to support the delivery of safe care. Staff wore personal protective equipment in line with regulations. Hazardous and clinical waste was responsibly managed.

The department had a key risk relating to the distance from the ED to the CT scanner. Leaders had a draft SOP for transfer between the two environments, but this was not implemented at the time of the assessment. This was on the risk register, and there were plans to reconfigure the ED estate, including funding for a co-located CT scanner. The trust provided a risk assessment however, the review date was 5 July 2022 and there had been no assurance or changes to the risk in the last 12 months, with updates stating, "risk remains the same". The review date was 17 April 2025 and there was no target completion date.Staff told us patients requiring a surgical admission were only accepted with a CT scan, which could expose them to unnecessary radiation. We raised concerns with the trust and asked for an action plan to address our concerns relating to the CT scanner.

The trust told us the distance to the CT scanner was being addressed by a funding bid. Work on staff complying with CT standards and further education was planned but there was no date given, or plan and we did not intentions to audit or review patients who may have been exposed to radiation unnecessarily.

The ED did not have a suitable environment for adults with a mental health need. Staff told us they would use a bed close to the nurse’s station, or the family room which was not an observable area and there was no alarm system in place. The trust told us patients were not left alone in the family room, however there was limited risk mitigation in place in this room for staff safety.

The department had limited space in the resus area with three cramped cubicles available. Staff highlighted the risk this posed on managing critically ill patients getting timely care and treatment but told us they had not reported it. The trust had made a funding bid and planned to rebuild the ED to manage future demand if the bid was successful.Staff told us patients sometimes slept or received care like IV fluids in the ED waiting room overnight if there was no room in the department. Some staff told us it felt unsafe to have people overnight in the waiting room and expressed concerns about overcrowding and lack of space; we heard about 1 occasion when staff went to collect a child waiting in ED and their parent was asleep on the floor next to them.

Equipment for paediatric patients was stored in the main ED storeroom, the paediatric ED and the paediatric resuscitation room. Resuscitation equipment was regularly checked in line with trust guidance and stored in the paediatric resuscitation room for quick access in an emergency. The waiting area was child friendly, had low level toys such as a play kitchen, and sensory lava lamp, but not big enough for the number of children attending. There was wall art throughout the paediatric ED making it a child friendly environment.

Staff told us that at busy times the resus bay was used to assess and give treatment to children waiting, however, this could not be used during a paediatric resuscitation and then children had to wait for a cubicle to become free.

The emergency paediatric airway trolley was stored in paediatric ED and checked by operating department practitioners each day.

There was a small waiting area for children which could accommodate 1-2 families. Staff told us children often had to wait in the adult waiting area which could cause them distress. Staff gave examples where children had witnessed adults under the influence of alcohol or drugs, and with police in the adult waiting area which was distressing.

The FFT survey results, were positive at 92% showed areas for improvement, and one of the top 5 negative themes of feedback was facilities and comfort. Patients commented positively, including on the cleanliness and organisation of the facilities which contributed to a better overall experience. A small number of patients complained about limited seating, unclean waiting areas, and lack of amenities like food or drinks.

There was a 'Fit to Sit' area with nurse oversight. The service managed its attendance and capacity by assessing patient's needs in appropriate spaces.

Stock and equipment levels were appropriate, and staff had access to the appropriate equipment. We checked equipment in the department and found calibration and safety testing had been completed. PPE was available for staff, patients and visitors and we had no concerns about staff taking appropriate precautions.

Leaders and staff told us there were plans to expand and re-configure the ED to address some of the key risks in the department, including the paediatric ED, the CT scanner distance and the lack of suitable environment for mental health patients.

There were not always enough skilled and experienced staff in the paediatric emergency department. Due to recruitment challenges, there was not always the required numbers of children’s nurses available, risk was mitigated by adult nurses, but leaders did not have oversight of those who had children’s nursing competencies, and staff were not always confident in the training they received. There were enough medical staff to meet the planned rota and according to national guidance with gaps in the rota covered by locum consultants. There were not always enough nurses to cover the rota, there were rota gaps, and adult nurses were often moved to cover the paediatric ED.

Staff were kept up to date with mandatory training however we did not see evidence of role-specific training or education. Appraisals were not in line with trust targets, however medical students and newly qualified nurses were generally happy with the support they received.

The service did not meet national staffing guidance which states the paediatric ED should always be staffed by two registered children’s nurses (RCNs), and we were not provided with clear evidence or robust systems for competency-based training for adult nurses who covered the paediatric ED. There were 8 RCNs in post and 4 vacancies. Since our assessment, three RCNs had been recruited and were due to start in October 2025.

This was mitigated by registered nurses (adult) supporting the department, but it was unclear whether the adult nurses had completed paediatric competencies. Following our assessment the trust sent us information in relation to adult nurses competencies that had been completed and further mitigation the trust had taken.

Staff told us they had raised concerns about staffing in the paediatric department. They told us it was stressful to cover breaks and covering the department if an emergency patient attended was a concern.Whilst staff felt listened to in the moment, they did not feel action had been taken to resolve their concerns. They told us “Paeds feels like it is a bit forgotten”.

Leaders were not clear which adult nurses had paediatric competencies, and when we reviewed competency booklets, the only reference to paediatrics was child safeguarding training. Actions taken by leaders to mitigate risk were not fully in line with CQCs published policy position.

Staff and leaders told us paediatric staffing was an ongoing issue during the assessment in March 2025 in the ED, however it was not discussed regularly at the directorate meeting. We reviewed minutes for 3 months, November and December 2024 and February 2025, and there was no mention of paediatric staffing issues or mitigations.

We raised our concerns with the trust in March and April 2025, and they responded with actions they had taken and planned to take to address the issues. Initial actions included understanding the oversight systems and resources available to staff. Further actions included introducing systems to monitor staff competency and staffing cover in paediatrics, reviewing and increasing oversight of training and development, recruiting to vacancies and honing the paediatric action plan to develop relationships.

Time was needed for staff to embed learning and skills, and the service should now continue to proactively monitor staffing and competencies in the paediatric ED, to ensure safe care and treatment is provided to patients by suitably qualified and experienced staff.

The service did not have a Paediatric Emergency Medicine (PEM) consultant, which was not in line with RCPCH standards, and the role had been open for recruitment in 2021 and 2023.

We raised concerns and the trust provided information about actions they had taken to address them. They were actively recruiting a PEM consultant and mitigating actions included all ED consultants being accredited with formal paediatric training, had advanced paediatric life support (APLS) or equivalent training, and 50% of consultants were instructors on for these courses. A paediatric lead consultant had dedicated time in their job plan to focus on development, training and oversight of paediatrics in the ED.

Although this mitigated some of the risks, the service was not meeting the standard, staff told us that medical staff confidence and competency varied in paediatrics, which had resulted in near misses.

Consultant cover was available from 8am to 10pm, which was less than the recommended hours. According to the Royal College of Emergency Medicine (RCEM), consultant cover should be from 8am to 12am, followed by on-call availability. The reduced consultant hours may affect the quality of care and decision-making processes in the ED.

The registrar rota had recently been redesigned. Approximately 10% of shifts were covered by locum doctors who described they are familiar with the department, received adequate induction and training, and were required to demonstrate appropriate training, for example advanced life support (ALS). Appropriate cover was arranged for resident doctor teaching.

Medical rotas for March 2025 showed there were generally 4 shift patterns across 24 hours, with an additional shift for tier 3 doctors to cover minors. There were low numbers of unfilled shifts for medical staff.

The service had enough staff to cover the adult nursing rota, however we saw a small number of gaps when we reviewed rotas. A twilight shift had been added where there were night shift gaps, which supported cover.

During the assessment, there were enough nursing staff on duty to meet the needs of adult patients in the department, however the workforce was fairly junior, so skill mix was sometimes a challenge. The nurse in charge made allocated staff based on the skills and experience needed in each area. However, there was not always registered nursing staff allocated to the waiting area, and we saw patients receiving treatment and being assessed in this area.

Staff were kept up to date with mandatory training however we did not see evidence of role-specific training or education.

Mandatory training compliance ranged from 58.7% for healthcare scientists to 94.8% for estates and ancillary staff. Compliance for medical and dental staff was 77.9% and 94.2% for nursing and midwifery registered staff. Overall compliance was 90.5. By May 2025, the trust told us most staff had completed mandatory training, and compliance had improved.

We were unable to determine whether the training received by staff was suitable for their role, including if mental capacity act and deprivation of liberty safeguards (DoLS) training was included, because the data did not include module details, or a breakdown for each role.

Simulation training, including multidisciplinary team (MDT) paediatric simulation, happened in the ED, and we saw a summary of findings from a recent simulation, but it was not clear who attended, when it happened or how learning was shared. As the trust had implemented processes to increase oversight of paediatric competency in adult nurses, this could inform simulation inclusion going forwards.

Staff had opportunities to learn about treating patients with learning disabilities and autism. Around 80% of staff had undertaken Oliver McGowan training, and last year the specialist nurse undertook Anna Freud training, which will be rolled out to other staff at Warwick Hospital from March 2025.

Some staff told us they did not feel competent to triage children, and staff could not describe training they had received to do so.

The trust took action to address the concerns we raised about paediatric competencies in triage and we were assured there was training available. To address staff feeling competent, the paediatric mandatory and essential training packages were being reviewed and relaunched in May 2025.

The March 2025 divisional workforce report showed in February 2025, staff turnover, vacancy rate and mandatory training compliance met the trust target, however appraisal rates did not, and had not since July 2024. Overall sickness, long term and short-term sickness rates for January 2025 were higher than the trust target. AE nursing staff and admin staff were above the target. The vacancy rate for the division was low was at 2.1%. We could not determine the vacancy rate for the emergency department, because the report did not provide figures at this level.

Staff did not always receive appraisals. Compliance for most staff groups was below the trust target of 85% and ranged from 40.8% for medical and dental staff to 100% for ED consultants. We asked for figures relating to the emergency department, but it appeared most staff group figures were given at division level, for example 61.4% of 389 nursing and midwifery registered staff had received an appraisal. This staff group count was much higher that the departmental establishment. In May 2025, the trust told us appraisal compliance had improved.

Newly qualified and overseas nurses told us they were supported to embed in the department by existing staff.

Generally medical students were positive about their training experience and had enough supervision to meet their needs. The 2024 national training survey showed the best performing area was clinical supervision in and out of hours. Areas that scored lower included induction, educational supervision, educational governance and supportive environment.

The service managed the risk of infection well. Staff followed infection prevention and control (IPC) processes and patients who required a separate room were generally able to have that so barrier nursing could be effective. However, audits showed varying performance in cleanliness and IPC.

The environment of the main and paediatric ED was clean, and clinical waste was disposed of appropriately.

Personal protective equipment including gloves, aprons and masks were available, and they were used and disposed of appropriately by staff. We observed staff using appropriate personal protective equipment (PPE) when treating patients.

There were individual rooms so patients could be barrier nursed if that was needed. However, we saw some of the paint and wall art was peeling off the walls in the paediatric ED.

Leaders recognised increased risk of cross infection and put in measures to reduce this where possible. Visitors and patients were asked to wear face coverings because there were several respiratory illnesses prevalent in the area. This was compulsory for staff. We did not observe patients were routinely offered face masks.

We observed an example of staff not following infection prevention and control processes in the department. Dirty linen from a barrier room was left in the hallway not bagged in line with the trust process, and staff left the barrier nursing room and entered resus to wash their hands. We asked staff and they were unclear on the policy to prevent cross contamination. We escalated this to the nurse in charge during the assessment. This was a risk because there was an increased likelihood of spreading infection.

Hand hygiene audits showed 100% compliance for every month from May 2024 to February 2025.

Regular cleaning audits we completed and in February and March 2025 and performance for the department maintained at 98%.

An audit of infection control practices and environmental cleanliness on 9th July 2024 showed out of 9 standards, 4 met the standard, 1 needed attention, and 4 needed urgent attention. The audit compliance was 79% which was needed urgent attention. The areas that did not meet the standard were ward environment, hand hygiene, decontamination, sharps handling and disposal, and care of equipment. A comprehensive action plan was developed and most actions closed.

The Trust had safe systems for appropriate and safe handling of medicines to ensure people were given their medicines as prescribed. Medicines storage was locked and secure with access only to authorised staff.Staff knew how to contact pharmacy for support and advice and there was good access to a clinical pharmacist within the emergency department

Although there was no clinical pharmacy service based within the emergency department there was good support from pharmacy during busy times. Processes ensured people received their medicines as prescribed. Medicine administration records were documented including recording a reason if a medicine had not been administered.

We observed a clinical pharmacist visiting ED to focus on medicines supply, prioritise patients who were going to be admitted and any high-risk patients. The pharmacist helped to ensure that patients did not miss doses of critical medicines as well as improve the flow and transfer of patients out of ED. A recent critical incident in ED (January 2025) demonstrated the value and benefit of having a strong pharmacy presence within ED to undertake medication history and reconciliation and they were able to ensure there were supplies of medicines to prevent any missed doses.

We reviewed three medicine administration records and observed clinical checks being undertaken by the pharmacist. Any discrepancies or medicine issues were recorded to ensure the effective continuation of treatment for the patient.

Allergies were highlighted, and recorded on medicines, so they could be prescribed safely.

There was a process for managing and reporting any errors or incidents involving medicines. Staff were able to talk through the process that would be followed if this occurred. Medicine incidents would be discussed within the team at team huddles.

Medicines were stored in accordance with guidance. It was locked and secure with access only to authorised staff, medicines requiring refrigeration were stored at the right temperature and medicines for resuscitation in an emergency and controlled drugs were stored in line with requirements. Members of the pharmacy team undertook audits, stock checks and ensured stock levels were sufficient for the department.

Staff told us that pharmacy conducted audits on the safe and secure handling of medicines. We saw evidence of detailed storage audits with solutions and action plans implemented where issues were identified.

Time critical medicines (TCMs) are medicines that must be administered at specific times to avoid potential harm to patients. The service monitored any missed TCMs and reviewed the reported themes every month. In June 2024 identified areas for improvement were a delay starting antibiotics for neutropenic sepsis patients. Lead clinicians from the ED were involved in developing and implementing short term and longer-term actions to address and during a critical incident in January 2025, additional pharmacy support in the department improved compliance with timeliness and increased medicines reconciliation for patients. The service was looking at how to implement this increased pharmacy support as a business-as-usual approach.