Diana Princess of Wales 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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question Requires Improvement. At this assessment, the rating has remained Requires Improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service enabled people to raise concerns. Managers investigated incidents thoroughly and people were protected and kept safe. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff involved people in planning any changes.

The service did not always manage medicines or the risk of infection. The training provided was comprehensive, but the service did not ensure that all staff completed it.

We have not awarded this service a score for Safe.

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

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

All staff we spoke with could articulate what constituted an incident and how they would report it. Staff were encouraged by senior leaders to report incidents, as the department promoted a fair learning culture and staff told us incidents were essential for learning.
Incidents were shared in staff meetings, and any themes or trends were shared in the daily huddles that were held throughout each day.

We reviewed all incidents that had been reported in the 6 months preceding inspection and saw a wide range of issues being reported with no themes or trends. We also saw that learning from incidents was identified and the department would use this for staff education.

All staff we spoke with were able to articulate the complaints process and how they would facilitate patients making a complaint. We noted that staff would proactively request feedback and that equal importance was given to both positive and negative issues. We noted multiple examples of information regarding the complaints process distributed across the department.

We reviewed 5 complaints received by the department prior to inspection and found that all were managed appropriately and were investigated, actions were identified and responded to within the appropriate timescale. Where learning was identified, actions were shared with staff.

All staff were aware of their responsibilities under duty of candour and were able to give examples of when they had applied these principles. There was an up to date policy covering duty of candour.

Risks were managed by senior leaders within the department, and all senior leaders could articulate the highest risks in the department. The highest risk at time of the inspection was overcrowding in the department and a lack of onward patient flow into the hospital which would lead to delays in patients receiving timely care.

We saw a positive culture of safety and learning. There was a fair learning approach which empowered staff to report concerns or issues without fear of negative consequences.

Staff learnt from incidents and complaints because senior leaders shared learning and actions taken through meetings, huddles and other communications.

The evidence shows some shortfalls in the timely assessment of patients who self presented to the department.

On arrival to the emergency department, patients who self-attended were booked into the department by a receptionist who passed the details to a senior nurse for review and allocated patients to the most appropriate area.

We observed high numbers of people self-presenting to the department. This combined with high overall patient volumes and reduced flow, resulted in delays to initial assessment. Staff were not able to provide effective oversight of patients waiting to be seen. As a consequence, some patients requiring prompt treatment were waiting longer than appropriate. We saw one patient who required urgent escalation due to clinical deterioration but had not received an initial assessment because of extended waits. This did not provide assurance that patients’ needs were consistently met within appropriate timeframes or that deterioration would always be recognised and escalated promptly.

The trust was not participating in the national initiative requiring ambulance crews to hand over patients within a maximum of 45 minutes to enable them to respond to emergency calls. As a result, patients experienced prolonged waits on ambulances due to high capacity within the department. Staff told us that in the weeks prior to the inspection, some patients had waited in excess of 5 hours for handover.

Senior staff were allocated to all clinical areas to maintain oversight. There were board rounds and safety huddles undertaken throughout the day. All board rounds and huddles were led by senior clinicians and recorded as being completed. We observed that all huddles and board rounds contained all pertinent information to enable effective oversight.

Clinical responsibility for patients within the department was clearly defined. All patients within the department were cared for by the emergency department staff including those awaiting admission under other medical or surgical specialities. We noted the emergency department staff retained medical oversight and nursing care for those patients. This caused increased demand on the staff and space available for patients.

The service had 24-hour access to specialist mental health support. We reviewed previously undertaken mental health risk assessments and saw no errors or omissions.

We saw examples of electronic discharge summaries being completed which contained all relevant information about the patients stay in the department if they were discharged home.

Bed management meetings were held throughout the day. The purpose of these meetings was to maintain oversight and grip of patient flow across the hospital.

The evidence shows some shortfalls, as there was no assurance that all staff understood their role in safeguarding. Training was provided, but not all staff completed it to the required level.

We saw that not all staff were trained to the appropriate safeguarding level as determined by intercollegiate safeguarding guidance for their role.

We saw that compliance with safeguarding adults level 3 training for nursing staff was 77%, which was below the trust target of 85%.

Some medical staff were not compliant with Level 3 safeguarding training for either adults or children. Compliance for safeguarding adults Level 3 was 48%, and for safeguarding children Level 3 was 64%, both below the trust target of 85%.

We also noted that safeguarding supervision training was only completed by 33% of medical staff and 75% of nursing staff.

Additional training had been completed in deprivation of liberty safeguards and Mental Capacity Act by 91% of all staff.

We did note that 88% of nursing staff were compliant with safeguarding children level 3 training which was above the trust target of 85%.

All staff knew how to make a safeguarding referral and would do so when appropriate. We also noted that feedback from safeguarding was included in staff meetings and daily staff huddles. Feedback was also shared by email to ensure all staff received it.

All staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. We saw multiple examples of patient notes being updated regarding their status and that the electronic record included any relevant safeguarding details. We also noted staff asking about family members who the patient may have caring responsibilities for.

We saw examples of staff assessing patients' capacity and documenting it within the patient notes. All clinicians were able to articulate how they would assess a patient with mental health issues including the appropriate risk assessment.

The evidence showed a good standard. 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.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. We saw that staff had access to a full range of interpretation services.

We saw examples of staff proactively encouraging patients to provide feedback on the service. Staff completed risk assessments for each patient on admission / arrival, using a recognised tool and reviewed this regularly, including after any incident.

There was a flag on the electronic patient record system that alerted staff if a patient had a safeguarding or mental health concern. We saw examples of patient passports being used within the emergency department to enable awareness of specific patient need.

Staff used a nationally recognised tool to identify deteriorating patients and escalated them. Observations of vital signs were recorded by staff, and the national early warning score was calculated. These were recorded electronically. The service had a clear escalation policy for the deteriorating patient.

We saw that local audits had previously identified issues with the appropriate escalation actions not being taken when a patient deterioration had been recognised. We saw that actions had been implemented and steps taken to improve performance, we reviewed 10 sets of patient records and found appropriate recognition and escalation in all 10 examples.

Staff knew about and dealt with any specific risk issues such as possible sepsis. There is national guidance for how quickly patients should receive treatment for sepsis based on their presentation. Following review of departmental audits, we saw issues had been previously identified in regard to sepsis recognition and treatment. We saw that actions had been implemented and steps taken to improve performance, during inspection we saw no issues in regard to sepsis.

The evidence showed some shortfalls in relation to paediatric guidance and storage of equipment.

Following refurbishment, the paediatric waiting area was not compliant with national standards, as there was no audio or visual separation from the adult waiting area. During periods of high demand, adult patients were seated in the paediatric waiting area, which posed a potential risk to children. We raised this with senior leaders during the inspection. They were aware of the issue but were unable to provide assurance or explain why it had not been addressed. We also noted that it did not feature on the departmental risk register.

Patients felt the waiting area was busy and lacked space to accommodate the amount of people attending the emergency department. During inspection we saw more patients waiting than the waiting room could accommodate.

We undertook a review of equipment stored within the department and found multiple items that were out of date despite staff telling us that there were designated staff and processes to manage stock. This was escalated during inspection and immediate actions were introduced.

We reviewed emergency equipment that would be used in the management of patients exposed to contamination or infectious agents. We saw multiple examples of equipment such as respirators that were out of date and could not be considered appropriate for maintaining staff safety. We escalated this during inspection and received assurances that it would be immediately actioned.

The service participated in clinical environmental audits. We requested previous audits covering the last six months which showed 94% compliance. During inspection we saw no issues in relation to cleanliness.

The designated mental health assessment room was fully Psychiatric Liaison Accreditation Network compliant. We also noted that there were two allocated cubicles that could be made ligature free if required. We reviewed the risk assessments and found them complete and without omission.

All clinical and non-clinical waste was managed appropriately.

The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. The service was previously in breach of the regulations in relation to safe and effective staffing. Improvements were not found at this assessment, and the service remained in breach of this regulation.

We were not assured that all staff kept up to date with their mandatory training. Overall compliance for all staff groups was 82% against a trust target of 85% but we saw areas of concern in the completion of resuscitation training. We saw that only 61% of medical staff and 75% of nursing staff had completed advanced life support training. We also noted that only 34% of medical staff had completed advanced paediatric life support.

The department could not meet the standard for registered nurses (children) as referenced in Facing the Future standards for paediatric care. Adult trained nurses who had completed paediatric competencies were used to fill some gaps in rotas. Information provided following inspection showed only 64% of adult trained nurses had completed advanced paediatric life support which did not provide assurance that all staff were trained to the required standard.

All newly appointed staff were able to describe a period of being supernumerary when first in the emergency department. We did note that compliance for staff to provide training (preceptorship) for newly qualified staff was only 74% which did not provide assurance that training was consistently available.

Managers consistently supported all staff to develop through yearly, constructive appraisals of their work. The data provided showed that medical and nursing staff appraisal completion rate exceeded the trust target of 85% in the last 12 months.

The mandatory training for staff was comprehensive and when completed met the needs of patients and staff. The training covered topics such as infection prevention control, moving and handling, fire safety, equality diversity and inclusion, health and safety and information governance.

Senior leaders calculated and reviewed the number and grade of nurses, nursing assistants and healthcare assistants needed for each shift using a safer staffing tool. This assessed acuity and dependency twice a year to provide evidence-based decision making on workforce requirements.

All non-permanent staff we spoke with told us that they had a full orientation on their first shift in the emergency department.

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

We saw staff failing to use personal, protective equipment (PPE) correctly and saw staff coming out of cubicles and not removing their PPE before commencing additional tasks. We also noted a lack of handwashing from all grades of staff within the department.

We reviewed audit results following inspection and found that all environmental audits provided had highlighted repeated issues with hand hygiene, noncompliance with bare below the elbow and the incorrect use of PPE.

We escalated concerns with senior leaders within the department and immediate actions were put in place to improve compliance.

The evidence shows some shortfalls in safe systems and processes.

We reviewed a departmental sepsis audit undertaken from September to December 2025 which showed that only 41% of patients were screened within 30 minutes, 18% had documented escalation, and 36% received hourly fluid balance on time. Blood cultures were timely in 68% of cases, with no patients receiving two sets, and only 45% of antimicrobial prescriptions followed guidelines. We also noted that paediatric sepsis training had only been completed by 76% of medical staff.

We spoke with hospital pharmacy staff who confirmed that the department did not have a designated pharmacy lead, this is not in line with recommendations specified by the Royal College of Emergency Medicine.

Training compliance data provided following inspection showed that only 50% of medical staff had completed medicines management training.

We reviewed the results from the most recently completed controlled drugs audit and saw compliance rates of 83% and 76%. This was below the trust target of 85% and showed a deteriorating trend.

Controlled stationary such as, paper prescriptions were stored securely and monitored to ensure they were handled in line with trust policy. However, whilst audit information provided following inspection showed 100% compliance, we were not assured that this audit was regularly completed.

We reviewed departmental audits from the past 6 months and found ongoing issues with the storage and monitoring of syrup or liquid medications. This had been noted as a concern in 4 out of the last 6 audits and we saw limited improvement during inspection.

We reviewed medicines that were kept in emergency bags for patient transfers and found medicines that had expired, this included intravenous fluids.

People’s regular medicines and allergies were recorded upon arrival to the department and Summary Care Records were used to support this process.

Governance structures were in place for the management and review of patient group directions (PGDs). PGDs are written instructions to facilitate the supply or administration of medicines to patients, without a prescription. We saw that PGD’s were in the process of being rewritten to enable staff to administer a wider range of medicines.

The service had systems in place to support learning from safety alerts and incidents. We saw examples of learning boards that highlighted and promoted learning from medicine incidents.

Decision making processes were in place to ensure people’s behaviour was not controlled by excessive and inappropriate use of medicines.