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

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 checked people’s liberty was protected where this was in their best interests and in line with legislation.

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

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 service had a positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and reported safety events. Learning was identified and lessons were shared to embed good practice. There was an embedded learning culture, and the service used incidents to improve practice and reduce risk.

The Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. The provider had a policy which aligned with the guidance, and which was followed by staff.

Staff knew what incidents to report and how to report them. They raised concerns and reported incidents and near misses in line with trust policy. Staff said they were encouraged and supported to raise concerns about risks to safety. They felt confident that they would be treated with compassion and understanding, and would not be blamed, or treated negatively when they raised concerns.

The Integrated Performance Report included in board papers in December 2025 suggested that there was an increase in reporting of low harm incidents, which is a positive situation as it suggests a good reporting culture.

Learning from safety events was communicated and acted on. Staff told us they received feedback from incidents they had reported, and learning from incidents was shared in meetings and by email. We saw posters on the notice board in staff rooms with information about the current month’s incidents and lessons learnt, including details of actions taken.

Staff gave us examples of when safety incidents had been used as opportunities for learning, including, when a male patient had a short length (female) catheter inserted which caused him harm. Action was taken to mitigate future risk that included removing all short length catheters from the department, because both male and female patients can tolerate longer length (male) catheters.

The morning handover meeting or safety huddle for nursing staff was used as an opportunity to share learning from incidents. Doctors had a daily huddle, which the nurse in charge attended to ensure doctors received the same learning from incidents as nursing staff. The department had a monthly focus on an incident theme. At the time of our inspection, it was on labelling blood samples at the patient’s bedside. This was to reduce the risk of patient misidentification and resulting sample mix-ups, as well as the risk of treatment delays and complications.

When an incident caused harm to a patient, the trust’s Duty of Candour Policy required staff to provide the patient with a written explanation of what had happened and the actions being taken to prevent it from happening again

Risks were dealt with and were seen as an opportunity to put things right, learn and improve. Immediately following an incident staff had a consultant led hot debrief to look at what went well, and what opportunities there were to learn and improve and to provide staff with emotional support if needed. A second (cold) debrief would take place a few days or weeks after the incident. This was to revisit what happened and what learning could be taken from it and to check in with staff about their wellbeing.

Leaders reviewed incidents using the different characteristics and needs of people using the ED. For example, all incidents that involved a patient with dementia could be reviewed to ascertain if there were any emerging themes so learning could be identified and shared.

Staff were aware of the complaints and compliments process, and they could explain it to patients and relatives. Learning from complaints and compliments was shared with staff at staff meetings, in newsletters and in emails. We saw evidence on the ‘you said, we did’ posters displayed in patient areas that complaints had been used to improve the service.

We saw that harm caused to patients as well as the potential for harm was recorded on risk registers, along with actions to mitigate risk. For example, all the staff we spoke to were concerned about overcrowding in the department. Overcrowding was classed as a high risk on the departments risk register, this risk was reviewed regularly, and new actions were added to mitigate risk when they were identified.

Leaders were aware that extended patient stays (over 12 hours) in the ED could lead to an increased mortality rate. They submitted a daily incident report for all patients who had waited in the department harm for over 12 hours so the potential harm caused by longs waits was documented. They completed harm reviews for any patient that spent more than 48 hours in the department to assess the negative impacts (actual or potential) on patients from their long wait. The aim of harm reviews was to identify patterns, learn lessons, and prevent future harm through local improvements. They ensure accountability and drive system-wide learning by focusing on delays in care.

The service worked with people and healthcare partners to establish and try maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when people moved between different services.

The department used multiple electronic systems to record and monitor patients care. The main electronic system in use provided staff with oversight of patients in the department and included flags to identify people with additional needs, such as a learning disability, dementia, or an infectious illness.

The emergency department consistently performed better than the England average for ambulance handovers within 30 minutes, averaging 92.68 %. This meant that patients care and treatment was transferred to the emergency team in a timely way and that the risks associated with delays to patients awaiting an ambulance in the community were reduced. Intelligent conveyancing was used within the system and whilst this improved access across the system, it also presented a local risk to capacity and flow.

The demand on the service sometimes meant there were waits slightly over the standard 15 minutes wait to be triaged. Usually, the department performed well with an average daytime wait of 17 minutes and a night-time wait of 14 minutes during August and September 2025.

Staff were trained to use a standardised triage tool to determine how quickly patients needed to be seen. Triage on adults was completed by a Band 6 registered nurse (RN), and children were either assessed by a Band 6 registered children’s nurse (RCN) or an RN with paediatric competencies. This was an improvement since our last inspection.

Information about why patients had come into the department was entered into the electronic system which could be viewed as a dashboard. There was good oversight of the dashboard from the emergency physician in charge (EPIC) and nurse in charge (NIC) of the department.

They could see how long patients had been waiting to be seen in ED, PED and the MIU and assess who needed to be triaged more urgently.

Specialist teams based outside of the ED could also see information about patients so they could respond to patients that were likely to need their care. For example, the cardiology in-reach team identified a patient with left sided chest pain had been admitted so they went to help assess the patient and formulate a treatment plan.

Patients arriving by ambulance were seen on the back of the ambulance within 20 minutes of arriving if there was no space inside the ED to bring the patient into. The details of these patients were included on the department’s electronic dashboard, so the EPIC and NIC had continuous clinical oversight of them.

Oversight of patients in the waiting room had improved since our last inspection in March. Two nursing staff and 3 administration staff were present to support patients. The triage nurses saw patients in rooms located directly off the waiting room and could respond quickly if there was a clinical incident in the waiting room.

There was a gap in continuous clinical oversight of children in the PED due to the physical layout of the waiting room. To mitigate risk children were left in the care of their parents in the waiting area with a nurse regularly checking on them to monitor for clinical deterioration. However, the trust had a plan to expand the size of the PED. The plan included a dedicated staff workstation within the waiting area. This would allow for "eyes-on" visibility, ensuring immediate identification of any child whose condition worsened while waiting.

Staff made referrals to the external teams commissioned to work with patients who attended in mental health crisis. Staff completed an immediate assessment of the patient’s risk to themselves and others to inform the treatment plan.

When unexpected cancers were identified, staff ensured continuity of care by asking the patient’s GP to make the oncology referral unless the patient was admitted. All patients received an electronic summary of their ED treatment, a copy of the letter was also sent to the GP.

The trust worked with their system partners to deliver safe and up to date medical treatment. For example, they worked with ambulance trusts to ensure patients with suspected stroke were transferred for more appropriate specialist care at another hospital. They worked with ambulance trusts, GPs, and other healthcare providers to ensure they used services provided by the trust that could help prevent unnecessary hospital admissions.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff 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 received training in safeguarding adults and safeguarding children to levels commensurate with their roles. They had access to the safeguarding team for support and advice. All the staff we spoke with knew how to escalate a safeguarding concern. There were flow charts so staff could see the process they needed to follow if they had a concern about a person’s welfare. All staff knew who the senior safeguarding leads were, and they were able to describe the safeguarding process, give examples of past cases, and explain how they escalated concerns.

Information provided by the trust showed that there were lapses in recognising safeguarding risks, particularly in relation to ‘Think Family’. Safeguarding audits showed that some risks were not always identified, and the trust introduced measures to reduce this.

Two nurses from the safeguarding team were located in the local Multi Agency Safeguarding Hub (MASH). They had access to the trust’s electronic systems and were able to see details of the patients. This enabled them to identify missed safeguarding referrals and make the referral to the appropriate safeguarding team. The missed safeguarding opportunity would then be followed up by a member of the safeguarding team with the member of staff who failed to make the referral. These follow ups conversations, called safeguarding knowledge reviews, gave the team an opportunity to check a staff member’s understanding of safeguarding so they could offer targeted training and support.

The safeguarding knowledge reviews undertaken by the safeguarding team and ED managers demonstrated the need to return to face to face training. Face to face training had ceased during the COVID-19 pandemic. Knowledge reviews demonstrated the need for classroom-based learning so staff had the opportunity to discuss their experiences together, consider real life examples of missed opportunities for safeguarding, and feel supported by the wider team in their safeguarding development.

The safeguarding team dip‑sampled all adult referrals and reviewed every referral for children to ensure these met guidance. Deep dives into referral data found safeguarding concerns had not always been recorded on the required system, limiting effective auditing. In June 2025 the trust implemented a mandatory safeguarding assessment that cannot be bypassed to ensure consistent recording, and to strengthen the quality and completeness of safeguarding documentation. This increased compliance with recording requirements to 100%. Visibility of safeguarding concerns, and the quality of data available for audit and assurance subsequently improved. The safeguarding team continued to review all referrals for children, to ensure they met guidance. The team also worked closely with clinicians to improve coding practices and enable clearer identification of themes such as dog bites or youth violence so targeted training could be delivered as themes emerged.

The ED and PED benefitted from regular visits from members of the safeguarding team to support staff in recognising abuse. The team also provided bespoke face to face training for ED and PED staff in addition to their mandatory training. The training covered a range of subjects including, recognising domestic abuse, and the use of restraint. They used real life cases to look at lessons learnt and explored how things could have been done differently. They also offered training in ‘professional curiosity' to demonstrate how gathering, recording, and analysing safeguarding information could enhance staff understanding of the significance of safeguarding concerns, which in turn would lead to better referrals and safeguarding outcomes.

Auditing and re-auditing of safeguarding referrals was completed so the team could see how training impacted on their knowledge and quality of their referrals. Auditing showed an increase in the number of gold standard safeguarding referrals made for children and young people from 1.8% in June 2024 to 12% in March 2025, across the same time period the majority of referrals were either good or outstanding (62%).

The safeguarding team provided managers with training to develop their understanding of what staff safeguarding competencies should look like. This meant they could support their staff to enhance their understanding of safeguarding and their responsibilities during supervision and in appraisals. The safeguarding team also had leads for exploitation, learning disabilities (over 18s), and domestic abuse, who were available to support staff who had safeguarding concerns about patients that came under one of these categories.

There was a process for staff to follow when adults who were parents of dependent children left the ED without completing their treatment. An automatic referral was made to the children’s health visitor or school nurse team for them to identify if a safeguarding referral was necessary.

Safeguarding referrals for patients presenting in a mental health crisis was delegated to the external mental health teams under a working agreement. However, to ensure appropriate referrals had been made for all patients who attended the ED or PED the trust safeguarding team regularly met with the mental health trust leads to track referrals. They did this using a live safeguarding referral spreadsheet maintained and monitored by the safeguarding team. In addition to this tracking process, the team also recorded all escalations made to the local authority to ensure oversight of timeliness, thresholds and outcomes of referrals.

Safeguarding staff attended MASH meetings and local authority quality assurance meetings with their partner agencies to support robust monitoring of referrals, information sharing, and partnership decision making.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

There were processes to ensure patients were issued with an identity wrist band when they booked in at the main ED reception or ambulance receiving area. The reception desk was well staffed, and people were able to book in quickly. During the daytime all patients had a set of observations taken by nursing staff based in the main ED waiting room before being streamed by the Band 7 streaming nurse. For example, people were streamed to the ED, the PED, or the paediatric assessment unit, the medical assessment unit (MAU), the surgical assessment unit, the same day emergency care (SDEC). During the nighttime observations would be taken by the triage nurse. Clinical observations were recorded on the National Early Warning Score (NEWS2) for adults and the Paediatric Early Warning Score (PEWS) for children. The observations (vital signs) were used to help staff assess a patient's condition, identify potential deterioration, and guide clinical decisions. We saw NEWS2 and PEWS scores being completed in line with guidance and policy. The electronic oversight system flagged when patient observations were due and when NEWS2 and PEWS scores were due to be reassessed. This was an improvement since our last inspection.

The demand on the service meant there were sometimes waits over 15 minutes for triage for adults and children and young people. When waits for triage exceeded 15 minutes, a third triage nurse would be added to ensure all patients were triaged in a timely way, help reduce waiting times for all patients. Our inspection took place while the ED was managing an unprecedented number of patients. For example, in just 1 hour, we saw 29 new patients came into the ED for treatment. We saw waits for triage as low as 13 minutes and high as 64 minutes however the trust were able to provide us with data that demonstrated their waits for triage were typically much lower. For example, in July 2025 patients waited an average of 17 minutes for triage, in August they waited an average of 15 minutes, and an average wait of 17 minutes was recorded in September. The provider was in the process of giving training in triage to Band 5 nurses to increase the number of people who could be deployed to triage when demand on the service was high. Risks associated with long waits were mitigated by the waiting room nurse undertaking observations on patients as soon as they were booked in. If observations were of a concern, the patient would be flagged and seen urgently.

Due to the extreme demand on the service during our inspection additional senior nurses were placed into triage to reduce the backlog, and a consultant was placed at reception to make rapid decisions about how quickly people needed to be seen.

There were systems to identify critically ill patients when they arrived at the ED. The ambulance service informed the ED when a critically ill patients was being brought in by ambulance so they could be transferred straight to the resuscitation area. The EPIC and NIC had clinical oversight of patients in the department, including the waiting room, and could act quickly to move patients into the resuscitation area if patients deteriorated and became critically unwell. Resuscitation trolleys were located throughout the ED.

Mental health referrals were made for patients presenting in mental health crisis as soon as they were clinically well enough to have a psychiatric assessment. A 3-year RCEM audit demonstrated care for patients with mental health problems had improved over the course of the audit. Year 2 data showed the department were mostly performing above (better than) the national average. A mental health triage to gauge a patients risk of self-harm and/or leaving the department before an assessment or treatment was complete (complete mental health triage) was being completed within 15 minutes of arrival for 36.4% of patients (national average 31%), a complete mental health triage was completed within 30 minutes of arrival for 53.1% of patients (national average 44.6%), and 34.2% of patients had a brief risk assessment by ED clinician of suicide and further self- harm (national performance 34.2%). Although, the audit identified only 39.1% of medium or high-risk patients had an appropriate level of observation while in the department (the national average at that time was 42.7%).

The RCEM audit will not conclude until December 2025. However, the available data from year 3 demonstrates significant improvement in every category. Patients who had a complete mental health triage within 15 minutes of arrival had increased to 72%, patients who had a complete mental health triage within 30 minutes of arrival had increased to 87%, the proportion of patients who had a brief risk assessment by ED clinician of suicide and further self- harm increased to 64%. The number of patients who had received an appropriate level of observation had increased to 87%. High risk patients who required constant observation received 1 to 1 supervision from a designated member of staff.

When the department was full, staff followed a clearly defined escalation process to look at where patients could receive treatment. The trust had a policy not to nurse patients on corridors, they had designated spaces within the hospital that could be used at critical times, for example assessment rooms or spaces in the MAU or SDEC. Side rooms on designated wards could be opened up for use by 2, instead of 1 patient, to improve the flow of patients of out of the ED.

NEWS2 and PEWS were used to assess risk of clinical deterioration. There were clear escalation plans for staff to follow when sepsis or a deterioration was identified. This included the use of the national sepsis care bundle. We saw patients were escalated for a medical review when sepsis or deterioration was identified. Medics responded in line with guidance. However, we saw 1 patient who was not started on antibiotics within 1 hour.

Staff completed risk assessments for falls risk. When patients were at high risk of falls actions were taken to reduce the risk. For example, patients could be given socks with extra grip and have more frequent comfort rounding and be bedded in an area where there was a higher level of observation. Staff also completed risk assessments to identify patients at risk of tissue damage and venous thromboembolism (VTE).

The service mostly detected and controlled potential risks in the care environment. The service had enough suitable equipment to help them to safely care for patients, staff were trained in its use and kept equipment maintained. Leaders and staff took steps to make sure equipment, facilities and technology supported the delivery of safe care.

The PED and adult resuscitation bays had all equipment and space required to resuscitate and stabilise deteriorating patients.

The ED had 3 triage cubicles, 17 majors cubicles, a mental health cubicle, and a resuscitation area with 3 resuscitation bays. There was a fit to sit area with 5 reclining chairs, during times of escalation the number chairs would be increased to 7. Majors is an area for patients with serious and life-threatening conditions. People with non-life-threatening conditions who needed urgent treatment were streamed by a senior nurse to the MIU. Fit to sit was designed to be used at times of overcapacity to stop the use of corridor care. The patients in this area were assessed as having lower clinical acuity than other patients within majors. There was also a large public waiting room.

There was a room, called the sky room, for patients that were in the last hours of their life. This room was in a quieter part of the department. The relative’s room was located next to the sky room, the relatives room was small but was suitably furnished. Staff had raised money to decorate the sky room, and fundraising was underway to redecorate the relative’s room.

There was an ambulance triage area with 5 cubicles. Patients in this area received rapid triage and assessment by a senior doctor or advanced practitioner, for example an emergency nurse practitioner (ENP), so investigations and treatment could begin promptly and the plan to discharge or admit could be expedited.

The PED had 4 majors cubicles and 1 resuscitation room. The waiting room was small. It had 3 seats and there were toys to occupy toddlers and young children. The PED waiting room did not allow for continuous observation from staff. Once triaged, children and young people who were streamed for urgent and emergency care in the PED waited in either a PED cubicle, the PED waiting area, or waited in the main reception area. All patients including children had to access the service through the main (adults) waiting room to book in at reception. This exposed children and young people to the potential of seeing or hearing adult themed behaviour and conversations. However, staff told us they did not regularly have to ask children and young people and their parents and carers to wait in the main waiting room. Staff told us they regularly went into the PED waiting area to check on patients who were under constant supervision of their parents or carers.

There was a plan to increase the footprint of the ED and PED. The plans included significantly increasing the size of the PED waiting room to include a reception desk or nurses’ station to improve clinical oversight of patients. The planned building works were due to start in November 2025.

The MIU had 6 cubicles and 2 waiting areas, 1 for children and 1 for adults.

There was 1 mental health cubicle in majors. The cubicle was not fully compliant with Psychiatric Liaison Accreditation Network (PLAN) standards. There was an alarm strip which was in good working order and there were 2 doors to the cubicle so staff could escape if they felt threatened. However, there were some ligature points in the room, and the furniture was standard hospital furniture that could be easily picked up and used as a weapon. Staff also told us the second door in room was sometimes blocked by equipment, and when it was not blocked, the door was awkward to use. We raised this as a concern and senior hospital leaders took immediate action to mitigate this risk. Staff told us they had secured charitable funding for improvements to a new mental health cubicle which would be ligature free and have specialist furniture that was difficult to lift to improve safety. Although funding for the improvements had been secured, staff wanted to wait until after the planned building had been completed before they used the money to make the changesTo mitigate risk, high risk mental health patients were not left unattended in the mental health cubicle. The mental health cubicle had been on the departmental risk register since 2023 and had board level oversight.

Staff told us the designated mental health cubicle was frequently used for general patients. However, they understood the reason for this was based on the clinical needs of patients and sometimes patients with mental health issues could be more effectively cared for elsewhere in the department. For example, in a room near the nurse's station so staff had clear visible oversight of patients who did not require 1 to 1 supervision from a member of staff.

There was not a designated mental health cubicle in the PED. However, staff could remove some equipment from a standard cubicle to reduce ligature risk, and they ensured children received constant supervision from parents, carers, or a designated member of staff. If children and young people presenting in a mental health crisis were delayed for more than 4 hrs waiting for a mental health assessment, they would be transferred to the children’s ward to ensure they were being cared for in a more suitable environment.

The resuscitation trolleys were fully equipped and checked regularly by staff. We saw emergency resuscitation equipment in all areas, including defibrillators, and anaphylaxis packs. Checks of resuscitation trolleys were completed using a quick response (QR) code. This enabled managers to be alerted to any checks that had not been performed so they could ensure the checks were completed. All the resuscitation trolleys we looked at contained consumables that were in date. However, some of the emergency resuscitation consumables in the resuscitation area were out of date. We raised this with the trust and all out of date consumables were removed.

We saw portable electronic equipment had been safety tested, and evidence of when equipment was next due to be serviced was visible on equipment.

Diagnostic imaging equipment was located within the ED, although there was no computed tomography (CT) scanner. CT scans are regularly required in ED for patients to check bones and organs after an accident. At the time of our inspection patients had to be taken to the main diagnostic imaging department for CT scanning. However, funding for a CT scanner had been agreed and it was due to be installed in the department early in 2026.

Members of the estates team conducted a weekly walk round of the department to assess if any equipment or furniture needed repair or replacement.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care that met people’s individual needs.

We saw a well-staffed ED. There were no unfilled vacancies at the time of our inspection. The trust had over recruited to some posts to ensure there were enough staff even when the demand on the department was higher than expected.

Staff were aware of the clinicians who were in charge of the department (NIC and EPIC) and what their own roles and responsibilities were.

There had been some improvements in nurse staffing in the PED since our last inspection. There were 2 staff assigned to work each shift. They were either 2 RCNs, or 1 RCN and 1 registered RN who had undertaken additional training in paediatric nursing and were signed off as competent to work with children. At the time of our inspection 27 RNs had completed level 1 paediatric competencies and 5 had obtained their level 2 competencies. There were plans for more RNs to complete paediatric competencies. In addition, 12 RNs were enrolled on a master course in emergency children’s nursing, and 2 RNs were undertaking training to become dual registered in children’s nursing. The department also had a nurse dedicated to the learning and development of both RCNs and RNs for paediatric skills and knowledge. RNs performing triage on children had completed additional training to triage children. This was an improvement since our last inspection.

Consultant staffing in the ED did not match RCEM guidance which recommended consultant cover between 8am and 12 midnight. Consultants covered from 8am to 10pm 7 days a week, with double cover on Monday and Tuesday evenings which were the busiest times of the week. There was a plan to increase the number of consultants working in the department from 12 to 15 in the short term and to 18 in the longer term to improve cover arrangements. However, to mitigate risk in staffing numbers the medical staffing in the ED was rostered using a tiering system to ensure the skill mix of doctors on the rota matched demand and promoted safe medical cover The tiers matched skills and competency rather than seniority as a doctor.

All doctors in the higher tiers were seconded to anaesthetics (to develop competency in airway management and sedation) for 3 months and provided with funded ultrasound and advanced life support training. The higher tiered doctors were also given acting up opportunities to ensure the skill mix remained stable. The tier system provided good skill mix throughout each 24-hour period, with at least 2 doctors from the top tier being rostered onto every shift.

The PED was not separately staffed from the adult ED for doctors. Clinical care was provided from the pool of doctors on duty. The trust had agreed a plan to train an existing consultant in emergency medicine in paediatric emergency medicine. Other consultants had been identified to receive training in paediatric emergency medicine, although this would not be accredited training due to the challenge of limited national training spaces.

Resident doctors had protected weekly consultant led clinical teaching time, and regular supervision with consultants. New medical staff were supernumerary for between 4 and 6 weeks. Doctors told us that they felt well supported in the department.

There was an innovative recruitment and retention process to make working in the ED more attractive. Doctors were employed part time substantively and part time as a locum which meant doctors worked 1 in 4 weekends instead of the more typical 1 in 3, but they had the opportunity to cover more weekends if they wanted to.

A recognised staffing tool for nursing staff was used to staff the ED. The efficacy of the tool was due to be reviewed to ensure it was still an appropriate tool to staff the department. In the ED there were 18 RNs, 3 nursing assistants (NAs), and 6 Healthcare Assistants (HCAs) on each shift. The planned number of nursing staff matched the actual numbers of staff in the department on the days of our inspection.

The clinical learning team ensured nursing staff received the training they required. All new starters received an induction book, so they understood the processes they needed to follow and learning they needed to complete. They were supernumerary for a minimum of 12 shifts. The clinical learning team provided study days for Band 4 and 5 nurses. The most recent study day had been used to complete sepsis training. The team told us they had added end of life care training to their training schedule as they identified there was a gap in knowledge for some staff.

The clinical learning team had developed tools to give them oversight of which staff required training and which staff needed competencies signing off. This meant they could schedule training to meet demand. However, a member of the team explained they had been working to improve compliance with the number of nurses trained to deliver triage and so there were gaps in some basic competency sign offs. For example, 44% of staff required ECG competency sign off, 32% required venepuncture competency sign off, and 31% of staff required cannulation competency sign off. Most the staff without signed off competency were new staff who started in the month prior to the inspection. Or staff who had been in the department for several years and had their competency completed prior to the current training system being developed. After the inspection the trust provided us with information to show training had had improved competency sign off to 69% for ECGs and 76% for venepuncture and cannulation.

Staff told us there were routes for development within the department. For example, 4 ENP posts had been created that existing staff could be developed into.

The department was supported by advanced clinical practitioners (ACPs). ACPs came from a range of backgrounds and included nurses and paramedics who had gained additional qualifications to support the delivery of emergency care. Their skills meant they could provide safe and effective immediate care for patients with a wide range of conditions including those that were life-threatening. There was a plan to increase the number of ACPs across the department.

The MIU was staffed by a combination of GPs, ACPs and RNs.

At the time of our assessment, overall compliance with mandatory training, including safeguarding training, in the PED and ED was 88%.

All staff in the ED and PED completed paediatric immediate life support training as part of their mandatory training. The Band 7 nurses had completed the European paediatric advanced life support training along with some of the Band 6 RNs and all of the Band 6 RCNs. There were plans for more nurses to complete this training course. Compliance for refresher training in immediate life support (ILS) (for adults) was 31%. Staff explained it was difficult to get staff onto the monthly face to face training sessions because this was part of mandatory staff training for the whole trust clinical staff group. To improve compliance the clinical learning team were planning on training some ED staff to deliver the ILS training in house.

Staff told us they received a monthly masterclass to improve their understanding of, and confidence in, dealing with challenging situations. For example, the sudden unexpected death of a child, people presenting in an acute mental health crisis, safeguarding, and resuscitation scenarios. A specialist team delivered bespoke training in resuscitation for the resuscitation team using lifelike, computerised, manikins. The manikins could be controlled by the training team to mimic a deteriorating patient (including temperature, pulse rate, respiration rate, and blood pressure), to give staff an opportunity to test and develop their clinical skills through a series of life-like simulated patient experiences in a risk-free environment.

Staff told us they had regular appraisals where they were given the opportunity to discuss their learning and development needs. A new electronic system had been introduced to record staff appraisals and mandatory training compliance, staff explained the new system could not fully communicate with the old system, the new system showed compliance as lower than the actual rates. However, managers retained access to the old system so they could maintain correct oversight of training and appraisal compliance.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The environment was visibly clean and clutter free with furnishings in a good state of repair. There was a strict approach to auditing cleanliness. If any area scored below 98% an action plan was devised to bring compliance to 100%. Patient and staff toilets were clean, and the cleaning schedules were on view and up to date. However, we could not find any evidence to show the children’s toys were cleaned in waiting room 2 in the MIU. We raised this as a concern and senior leaders acted immediately and found that toys were being cleaned but this was not recorded on a daily checklist. The cleaning checklist was amended to include a section for cleaning of toys.

The trust’s infection prevention and control (IPC) team ensured new infection risks were identified and communicated effectively to staff in the ED and PED. The IPC team made regular visits to the department. The team supported the department in making arrangements for potentially infectious patients who required isolation on arrival to reduce nosocomial infection risk. The IPC team also ensured information about infection risks were shared appropriately with staff, partner agencies, patients, and visitors.

There was an effective approach to assessing and managing infection risk in line with national guidance. For example, high risk patients were screened for Methicillin-resistant Staphylococcus aureus (MRSA). MRSA is a type of bacteria that usually lives harmlessly on the skin, if it gets inside the body, it can cause an infection that needs immediate treatment with antibiotics.

Staff performed regular local infection prevention and control audits including for cleaning, handwashing, staff uniform compliance, and observation of the environment. When audit results were below expected compliance action plans were developed to improve compliance.

Staff had access to and used personal protective equipment (PPE). We also saw PPE (face masks) for patients and other visitors to the department. Hand gel was available in all areas for use by staff, patients and other visitors.

We saw staff follow safe waste and clinical specimen management practices. There was appropriate segregation, storage, labelling, handling, and disposal of waste.

We observed staff were bare below the elbow and followed correct hand hygiene procedures. Staff uniforms were visibly clean, and staff could explain what their role was in infection prevention and control.

A minimum of two housekeepers worked in the department during the day and one housekeeper worked overnight to provide cleaning of the department and the equipment, and re-stocking IPC consumables.

Staff used ‘I am clean’ stickers after they had cleaned equipment and wiped surfaces down after each patient.

The service did not always make sure that medicines and treatments were safe and met patient’s needs, capabilities and preferences.

The RCEM recommends a dedicated emergency department pharmacist and pharmacy technician work within EDs as part of the multidisciplinary team to help provide clinical and operational support for the safe and efficient delivery of care to patients. At the time of our inspection there was no clinical pharmacy service based within the emergency department, however there was some support from pharmacy during busy times. Processes were in place to ensure people received their medicines as prescribed, and staff said that they knew how to contact pharmacy, and if the department was busy a member of the pharmacy team would visit to prioritise any high-risk patients who were going to be admitted. However, a Plan-Do-Study-Act (PDSA) was completed from 2 June to July 2 2025 to measure if the department would benefit from a dedicated pharmacist and technician 7 days a week. The PDSA demonstrated an improvement in medicines reconciliation, missed does of medicines including time critical medicines, drug histories being completed, and a 20% increase in dispensing speed. A business case was submitted to secure funding to ensure the department will have pharmacy support in line with national guidance in the future.

We observed a pharmacy technician undertaking a full medicine history with a patient and their relative. This ensured there was an accurate up to date record of patient’s medicines.

Nursing staff had access to time critical medicines. For example, there was dedicated storage for Parkinson’s Disease medicines as well as an out of hours cupboard and an on-call pharmacy service. In October 2025 the ED dashboard had a column added that highlighted patients with time critical medicines and if these had been prescribed or not. We reviewed a sample of medicine administration records which were recorded and completed in line with policy, including for a patient who required time critical medication.

Patients’ allergy status and medicine sensitivities were recorded on all medicine records seen. This meant allergies were highlighted, and medicines could be prescribed safely. We observed that one patient had been prescribed and administered one dose of an antibiotic which was documented in their medical records as a known allergy. Further treatment had been stopped, and an alternative antibiotic prescribed. On speaking with the patient there was no harm or adverse side effects experienced. Medicine incident reports had also identified that allergy status was not always followed which is important to reduce harm to patients and the potential for a fatal anaphylactic reaction.

VTE assessments were undertaken and recorded to evaluate patients’ risk of developing blood clots. We observed that preventative treatment was prescribed where appropriate.

Sepsis treatment followed antimicrobial guidelines which included documenting the decision with the antibiotic treatment recorded. Staff said the sepsis pathway was easy to follow with good training in place. When antibiotics were not given within timescales specified in the sepsis six bundle staff recorded this as an incident along with the reasons for delay.

There was a process in place 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 management training was mandatory which ensured staff understood the process and systems for safe medicine management. Staff told us they had online access to relevant medicine policies, procedures and guidelines.

Medicines were locked and secure but were not always stored safely in line with recommended practice. Staff did not consistently put medicines back into their original container which meant storage could be untidy. This increased the risk of medicines errors. This issue had been identified on medicines audits but had not been rectified. However, we did not see evidence of patients coming to harm as a result of this.

Medicines storage including controlled drugs were locked and secure with access only to authorised staff. Members of the pharmacy team undertook 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. The most recent medicine storage audits identified some unsafe storage practices which included loose medicines not stored in their original container. We observed the same issue which meant that there was an increased risk of an error when picking a medicine. There was a lack of storage space or a medicine preparation area in the PED. However, this was a known risk which would be resolved when the PED improvement works were completed in 2026.

Medicines for refrigeration were stored securely with records available of maximum and minimum temperatures to ensure the medicines were stored safely. Staff knew what action to take if there were any issues to ensure the safe storage of medicines.

Emergency equipment and medicines were available and checked in accordance with national guidance to ensure the medicines were safe to use. However, a regulator on one oxygen cylinder was out of date, which was immediately replaced during the visit.

There were pre-packed supplies of the most prescribed take home medications to reduce the amount of time patients had to wait to be discharged.

Staff told us they were concerned about the use of multiple systems used for prescribing. Different systems were used at different times in a patient’s treatment pathway which increased the risk of medicines errors. We saw these risks reflected on the departments risk register along with actions being taken to mitigate risk. The process for prescribing is due to be unified once the trust’s new EPR system is introduced in 2026.