King's College 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 people were protected from abuse and avoidable harm. At our last assessment we rated this key question as 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 was in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 regulation 12 (safe care and treatment) for inconsistent application of patient wristbands, for unsafe provision of corridor care, for the control of substances hazardous to human health, for infection prevention and control issues, for issues regarding venous thromboembolism (VTE) risk assessments and prophylaxis, for issues regarding the timely administration of medicines, and for issues regarding Patient Group Directions (PGDs) used by the service. The service was in breach of regulation 15 (premises and equipment) for concerns about the service’s equipment. The service was in breach of regulation 18 (staffing) for not employing dedicated pharmacy staff and for the completion rates of some staff mandatory training.

We informed the trust of some of these issues in May 2026. When we returned in June 2026, we found improvements in the way the trust delivered corridor care, infection prevention and control standards, the safety of equipment available to staff, the application of patient wristbands, and the control of substances hazardous to human health.

There were also areas of positive practice. The service had a culture of reporting and learning from patient safety incidents, staff understood and reacted to safeguarding concerns, and the service was generally well-staffed.

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 proactive and positive culture of promoting safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to identify and embed good practice.

Staff members understood what incidents were and how to report them. Staff members told us they were encouraged by senior staff to report patient safety incidents. This was reflected in the 2025 NHS Staff Survey, in which 91.2% of Emergency Department (ED) staff stated that they were encouraged to report errors, near misses, and incidents (this was a Trust-wide survey and therefore included staff at another ED run by the same trust). Staff members from the psychiatric liaison team, who were employed by a different NHS trust but were present in the ED, had access to the incident reporting systems of both trusts, ensuring that they could report incidents to either or both.

The service recorded a total of 1,156 patient safety incidents from May 2025 to April 2026. Most of these incidents resulted in no patient harm. Six incidents resulted in severe harm or death. The service had systems in place to ensure incidents were reviewed and started investigations where appropriate. We saw examples of changes made because of the recommendations of previous investigations, such as the use of point-of-care troponin testing for patients with chest pain, which was in place at the time of our inspection.

Learning from incidents was communicated in multiple ways, including individual feedback after submitting an incident, newsletters, emails from senior members of staff, teaching from practice development nurses, and through the ‘Big 5’ (a monthly list of areas for staff to focus on, which was emphasised at handovers). Staff were able to recall specific incidents and changes made as a result.

However, some staff members expressed concern that not all episodes of violence and aggression from patients were reported by staff. These members of staff told us that staff members often would not submit an incident for low-level violence and aggression incidents because the incident reporting form took too long to complete when compared with the high number of incidents they dealt with. They expressed concern that the recorded incident data for violence and aggression did not accurately reflect the frequency of incidents occurring in the department.

The service did not always work well with people to establish and maintain safe systems of care. They did not always manage or monitor people’s safety.

From May 2025 to April 2026, the service saw 105,820 adults and 21,637 children. This is a higher number of attendances than the service was designed for. Of these attendances, 4,956 and 419 respectively were primarily for mental health reasons.

During our visit in May 2026, patients were receiving care in the Emergency Department (ED) without identity wristbands being applied. The service had a policy that wristbands should be applied when first seen by a triage nurse or immediately when a patient arrives by ambulance. This policy was not being followed. We saw many patients without wristbands after they had been triaged, and observed staff not applying wristbands during triage. We saw staff administering medications, including controlled drugs, to patients without wristbands on multiple occasions. Staff relied solely on verbal identification for administering these medicines. This increased the risk of misidentification of patients, and therefore of medication errors. It also increased the risk that patients would not be able to be identified if they became unresponsive. When we raised this with the trust, they made immediate improvements. When we returned in June 2026, all patients we saw had a wristband on, and the trust provided evidence of a new daily wristband audit which also showed 100% of patients were now receiving wristbands.

Patients requiring admission were not transferred to wards in a timely manner. This was true for patients requiring a bed within the hospital and for patients requiring a bed at mental health hospitals run by another NHS trust. This was because of operational pressures on the service. There was higher demand for inpatient beds than the hospital or the local mental health NHS trust had available. While we were on site, there were 26 patients waiting for a bed, 8 of whom were waiting for a mental health bed. This resulted in patients waiting in the ED for long periods of time. Staff were aware of and were concerned about this issue and expressed frustration about not having the power to resolve it. The high numbers of mental health patients remaining within the ED impeded the ability of staff to do their work. We observed a trauma call in the resuscitation area in which staff provided life-saving care to a patient while being shouted at by mental health patients in a nearby bay. Staff told us about other instances where they were distracted from caring for other patients (for example, incidents in which mental health patients entered the cubicles of other patients).

However, there were clear systems in place for when patients needed to be admitted, and staff told us that referral systems to specialty teams were easy to understand and easy to use. Medical staff also told us it was easy to refer patients to outpatient clinics if needed.

The service used the Manchester triage system to review walk-in patients. This was used appropriately and patients were subsequently guided to different areas of the department or to the on-site Urgent Treatment Centre (UTC) based on their clinical need. The service’s electronic patient record system allowed staff to add icons/flags to patient profiles, allowing triage staff to identify specific patient needs straight away. There was guidance in place for when triage times were high or when large numbers of patients were waiting for triage. However not all triage nursing staff we spoke with were aware of this guidance or when to escalate to senior nurses. The service also had clear systems in place for receiving patients from ambulances.

The department was divided into different areas to serve different patient needs, including (but not limited to) a majors area, a resuscitation area, a dedicated paediatric area, an area for low-risk patients who could sit in a chair, and an area for low-risk psychiatric patients. There were clear guidelines in place for which patients could go to which areas and patients were streamed to these areas appropriately.

The service had systems in place to ensure that life-saving emergencies were prioritised and treated quickly. The service used trauma calls, stroke calls, and cardiac arrest calls to ensure that relevant staff attended in those circumstances. We observed a trauma call and found that all required team members were present and that the patient was stabilised and prioritised for a scan within 15 minutes. The service also had a ‘code 10’ call in place for patients with an acute behavioural disturbance, which alerted senior staff and security. If the patient arrived by ambulance, this could be activated before their arrival to allow for quicker assessment.

Mental health services within the ED were provided by a different NHS trust with expertise in mental health assessments. Members of staff from this trust were always present within the ED to provide services such as mental health nursing and psychiatric liaison services. There were systems in place to ensure that these staff could provide good care (for example, these staff had access to the electronic records systems of both trusts, allowing them to see medical as well as psychiatric information).

Staff handed over information about patients to each other at the beginning and end of each shift. These handovers were of a high quality.

The service worked with people and healthcare partners to review and act on risks to people’s safety. Staff understood what safeguarding meant and protected people’s rights to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff had access to trust-wide adult and paediatric safeguarding policies. These policies were clear in how safeguarding responsibilities were divided and included examples of safeguarding concerns. There was also guidance specific to the Emergency Department (ED) available on the trust intranet.

There were clear systems in place to report safeguarding concerns. Safeguarding referrals were sent via the service’s electronic patient record. These were received by the hospital’s safeguarding team, who reviewed them and notified the local authority if necessary. The safeguarding team referred 501 adult ED safeguarding concerns to local authorities within the 12 months prior to our inspection. Service leaders told us they were unable to give a precise figure for children due to the volume and frequency of discussions with external bodies. However, they suggested trust-wide data indicated that on average between 70 and 90 children’s safeguarding cases progressed to formal multi-agency discussions every 3 months.

Staff understood what safeguarding meant. Staff knew and understood how to raise concerns and were able to give examples of safeguarding concerns they had raised in the past. Staff gave appropriate responses when asked how they would respond if they had urgent concerns about a patient’s safety (for example, if an at-risk patient absconded). Staff located in the ED but employed by a nearby NHS mental health trust also had a good understanding of safeguarding procedures.

The service offered mandatory safeguarding training to all relevant staff groups. Safeguarding adults level 2 training and safeguarding children level 2 training had been completed by 90% and 83% of medical staff respectively, and by 100% and 96% of nursing staff respectively.

There was effective oversight of safeguarding procedures. There was a designated ‘safeguarding lead’ clinician who could provide advice when required. There were also weekly adult and paediatric safeguarding meetings. Paediatric safeguarding meetings were attended by external stakeholders, such as health visitors and youth workers.

Between May 2025 and April 2026, 11.8% of children who attended the service re-attended within 7 days. The service ran a programme named ‘Needs Evaluation & Support Team for Emergency Department Attendances’ (NESTED) to support children who attended the ED regularly. As part of this programme, the service held monthly multi-disciplinary meetings to discuss the issues these children were facing. Outcomes from these meetings included raising safeguarding concerns with the local authority, additional support for families in the form of nursing follow-up calls, and advisory letters to the patient’s GP.

Quality Statement Score: 1

The service did not work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe and supportive.

The service cared for some patients in the corridor during periods when patient demand exceeded the space available within the department. Corridor care was given in 2 areas – within the main majors corridor, where there were many non-numbered chairs and armchairs, and within the ‘ambulance offload area’ (a corridor near the ambulance entrance), where there were 7 numbered spaces for patients on trolleys. We consistently saw patients within these areas and staff members told us that they provided corridor care in these areas every day.

Despite this, at the time of our initial visit in May 2026, the service did not have any policies for providing corridor care in the Emergency Department (ED). Staff were not aware of any guidance about which patients could and could not receive care in the corridor. This led to patients receiving care in the corridor when this was inappropriate. During our visit in May 2026, we saw 2 patients with dementia, 2 high-risk mental health patients (both of whom were subject to section 2 of the Mental Health Act 1983), and 1 patient with a National Early Warning Score 2 (NEWS2) score of 6 (indicating that they were unwell) receiving care in the corridor. This is contrary to NHS England corridor care guidance.

We raised these corridor care concerns with the trust and they made some immediate improvements. A trust-wide corridor care policy was signed off and published after our initial visit in May 2026. This included guidance specific to the ED and a list of ‘exclusion criteria’ (patient characteristics which indicate the patient is unsuitable to receive care in the corridor), such as having dementia, having a NEWS2 score of over 3, or having a confirmed communicable disease/infection. The trust told us it was training staff on how to use this policy.

We returned to the department in June 2026 to review these changes. ED staff were aware of the new corridor care policy, but not all had read it. Not all staff were able to tell us what types of patients the policy excluded from receiving corridor care. However, a poster of these exclusion criteria had been stuck to the wall by the ambulance handover area for quick reference. Staff members told us they had received informal training on this policy through discussions with managers, but no formal training. Staff told us that, since our first visit, the culture around corridor care had improved. They told us that managers listened to their concerns more and this resulted in vulnerable patients being moved to cubicles more often. When we reviewed the notes of patients receiving care in the corridor during our June 2026 visit, we had fewer concerns than in May. However, we still observed 1 patient with infectious diarrhoea who had been in the corridor for over 9 hours after this had been identified. This presented a risk to other patients in the area. We also observed 1 patient with mental health needs who had attended following an attempted suicide and found no documentation as to whether they met the policy’s exclusion criteria or not.

Nursing risk assessments were not always completed, even when patients had been in the department for a long time. We reviewed the notes of 10 patients in the majors area, each of whom had either been referred to a specialist team (with the shortest length of stay being 5 hours) or had been present for at least 7 hours. Of these, only 7 had a falls risk assessment completed. However, pressure ulcer risk assessments were completed more consistently, with this being completed for 9 of the 10 patients. Of the 10 patients reviewed, only 3 met the clinical criteria requiring a sepsis risk assessment, and all 3 had a sepsis risk assessment completed in accordance with the Trust's NEWS2 policy. The service provided evidence of internal auditing of some of these assessments, which showed similar results. However, sepsis risk assessments were not included in these audits. This meant service leaders were unaware of rates of completion of this risk assessment, and therefore could not implement any necessary changes.

Venous thromboembolism (VTE) risk assessments were not always completed. We reviewed the notes of 6 patients who had been in the Emergency Department (ED) for over 12 hours, all of whom had been referred to the medical team but had not yet been admitted to a ward. Of these, 0 had a VTE risk assessment completed and only 1 had VTE prophylaxis prescribed. This led to an increased risk of ED patients developing VTEs. We discussed this with senior leaders who told us that these assessments and prescriptions were the responsibility of specialist teams, and that patients staying in the ED for long periods after they had been referred to specialist teams had made the oversight of tasks like this more difficult. However, we were not told about any work being undertaken with specialist teams to improve this metric.

The service used appropriate warning scores, such as the National Early Warning Score 2 (NEWS2) for adult patients and the Paediatric Early Warning Score (PEWS) for children, to help staff assess patient observations. The service audited adult patient observations monthly – these audits showed compliance of 90% or above for the 12 months preceding the inspection. We reviewed the notes of 10 adult patients and found that 2 had not had observations repeated when they should have been. The service provided evidence of internal audits of PEWS scores between April and June 2026, in which 90 patient records were reviewed. These showed 100% compliance with PEWS requirements.

Risks to patients were identified at triage. For example, patients presenting with mental health concerns were identified and moved to the majors area so that they could be observed more easily. If these patients then left the department, clinicians were therefore aware of the risk this posed. Nurses who undertook triage duties were expected to undergo triage training. For the adult ED, 100% of nursing staff with triage duties had completed this training. For the paediatric ED, we were informed that 69.7% of all nurses had completed this training, and that nurses who had not completed this training did not undertake triage duties.

We observed that all patients had call bells, so could alert nursing staff if they needed help.

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

The service did not always ensure that chemicals that posed a risk to patient safety were kept securely. We found one cleaning product which is classed as a ‘substance hazardous to human health’, and is therefore subject to Control of Substances Hazardous to Human Health (COSHH) regulations, within an unlocked cupboard in an unlocked sluice room within the majors area. This resulted in a risk that a patient may consume or otherwise interact with this substance. This risk was heightened by the high number of patients with mental health concerns who were nearby. The service immediately removed this chemical when informed. We also found iodine-based antiseptic solutions stored on windowsills and in cupboards in areas where patients were present. This resulted in a risk that patients may consume them and suffer adverse health effects (however these items were not subject to COSHH regulations).

Sharps bins were not always safe for staff to use. We observed 3 overflowing sharps bins, resulting in a risk of needle-stick injuries to staff.

Processes for the checking of a difficult airway trolley in resus were unclear, resulting in staff confusion about when they were supposed to review the equipment kept in this trolley. As a result, we found 2 out-of-date items in this trolley, which again posed a risk that patients would be treated with faulty equipment.

There were significant issues with the emergency procedural kit boxes in resus. These were boxes of equipment needed in specific emergency situations, such as emergency Caesarean sections. Their intention is to ensure that staff have fast and easy access to all the equipment they would need in such a scenario. Some of these boxes were not sealed, some were broken, and some were sealed only with tape. This meant they could be accessed at any time for their contents without prompting a check or re-stock. Daily checks of these boxes were inconsistent and often incomplete. This resulted in it being unclear what these boxes contained. It also resulted in these boxes containing out-of-date equipment which again posed a risk to patient safety.

Faulty equipment took a long time to repair. While were on-site we observed a toilet that had been blocked for 3 days and a macerator that had been broken for a month. Audit documents provided by the trust showed additional examples, with one audit making note of a macerator that was broken “for months” and a “very slow response” to toilet concerns.

The service provided care for children within a separate area behind a locked door. To access this area staff had to swipe their identification card and members of the public had to ring a doorbell. The paediatric Emergency Department (ED) included a separate waiting area with toys for children to play with. However, consumable equipment within the paediatric ED was not always safe to use. We found 5 items with open or broken packaging and 7 out-of-date items in this area. This resulted in a risk that staff would use contaminated or faulty equipment when delivering care to children.

We informed the trust of these issues and they made immediate improvements. On our return in June 2026, we found no further chemicals subject to COSHH regulations kept in patient-accessible areas. However, we did find a surgical scrub solution (for which the manufacturer advised keeping out of reach of children) kept on a low shelf in an unlocked sluice room within the paediatric ED, which presented a risk that a child may consume it. We found no out-of-date or open consumable items anywhere within the ED (including the paediatric ED). We found no overflowing sharps bins. Service leaders had mostly clarified expectations around the checking of difficult airway trolleys and emergency procedural kit boxes in resus. However, it was still not clear on which days staff were expected to perform some monthly checks. We found no out-of-date items inside. The emergency procedural kit boxes had been transferred into new plastic boxes, which were sealed, and had a new system ensuring inventory checks were completed. We did not find any faulty equipment that had been reported more than 1 day previously.

The service provided rooms for the assessment of paediatric and adult patients with mental health needs. However more adults presented with mental health needs than there were such rooms available. For adults, these rooms were ligature-free and met Royal College of Psychiatrists guidelines. There was also an additional ligature-light cubicle available in resus to provide care to patients with joint physical and mental health needs. For children there were 2 rooms available, 1 of which had anti-ligature fittings and anti-barricade functions, and 1 of which was ‘ligature-light’ and was designed for joint medical and mental health care.

There were 2 waiting rooms for adult patients. Patients awaiting triage sat in the ‘blue waiting room’, which was a corridor near the ED entrance. Patients who were awaiting assessment after triage, but who did not require a space in majors, sat in the main waiting room. No members of staff were permanently housed in either of these spaces. However, both areas were relatively small, and staff regularly entered these areas to use them as corridors or to call patients. When staff called patients, they had sight of all areas of these waiting rooms. We were therefore assured that this provided adequate oversight of patients in these areas.

The service did not always ensure staff had undertaken adequate training to enable them to provide care that met people’s individual needs. However, the service ensured there were enough staff within the department.

The service provided mandatory training to all members of staff. Topics for mandatory training differed depending on the responsibilities of the role. Although we did not review the training provided, the topics were relevant and appropriate. Medical staff (doctors) had completion rates of 46% for ‘Sepsis in Adults’ training, 64% for ‘Blood Transfusion’ training, and 65% for ‘Suicide Awareness’ training. Administrative and clerical staff had completion rates of 61% for ‘Data Security Awareness’ and 42% for Oliver McGowan training (this is a training package regarding patients with learning disabilities). This meant not all staff had the most up-to-date information on these topics and led to a risk that staff may not be aware of changes to local processes. Training rates were generally higher (over 90%) for nursing staff.

Most staff members told us that they did not have concerns regarding staffing levels. They told us there were enough staff to do their job and that senior leaders generally found cover for absences. However, some members of staff reported that practice development nurses (PDNs) were often asked to cover nursing staff vacancies, and that this prevented them from focusing on staff education and training.

We reviewed staffing figures and rotas provided by the service. The overall vacancy rate across all positions in April 2026 was 5.0%, which was below the NHS England March 2026 average of 6.5%. Some of this was due to vacancies within the healthcare assistant (HCA) and nursing staffing groups. The service was funded for 23.87 full-time equivalent (FTE) band 3 HCAs, of which 8.27 positions were vacant. However, the service had an additional 1.61 FTE band 2 HCAs over its establishment. The service was funded for 89.14 FTE band 5 nurses, of which 12.98 were vacant. Vacant shifts were usually covered by bank staff. Of all nursing shift vacancies in April 2026, 77% were covered by either bank or agency staff. Most other role types, including consultant and resident doctors, were filled at or near their FTE funding. Medical shift vacancies were also filled by agency or bank staff 77% of the time in April 2026.

Nursing rotas for the previous 3 months showed that managers had calculated the types and numbers of staff required for adult and paediatric areas, and that these were met most of the time. Medical rotas were arranged so that there was in-person consultant cover from 8am to 12am, which was compliant with Royal College of Emergency Medicine (RCEM) guidance. The service employed 27.95 FTE consultants in April 2026 against an establishment of 27.80, while there were 127,457 attendances in the 12 months prior to this. This resulted in a ratio of 1 consultant per 4,560 attendances. This is less than the 1 consultant per 3,600 – 4,000 attendances recommended by the RCEM. However resident doctors did not describe lack of access to consultants as being a problem. The trust rostered 3 mental health nurses (employed by a different mental health NHS trust) on all shifts.

Annual turnover of most staff groups was relatively low (4% for band 6 nurses, and 0% for consultant doctors) but was higher for band 5 nurses (17%). Sickness was also relatively low, with an overall sickness rate of 3.9%.

Staff had received adequate training in managing medical emergencies and cardiac arrests. In April 2026, 90% of nursing staff had a valid Basic Life Support (BLS) or Immediate Life Support (ILS) qualification, and 96% of doctors who were required to completed an Advanced Life Support (ALS) qualification had done so (not all doctors are required to have a valid ALS qualification due to differing levels of experience). Of the 33 nurses employed by the paediatric ED, 31 had a valid paediatric life support qualification such as Paediatric Immediate Life Support (PILS), and the service had scheduled training for the remaining 2 nurses. The service ensured there was always a doctor with a valid Advanced Paediatric Life Support (APLS) certificate rostered on the paediatric ED.

Most clinical staff received an annual appraisal. In the 12 months to March 2026, 96% of nursing staff and 80% of medical staff had received an annual appraisal. This figure was lower (55%) for administrative and clerical staff.

The service did not adequately assess or manage the risk of infection. Clinical areas were not always clean, and staff engaged in poor hygiene practices. However, the service made significant improvements between our May 2026 and June 2026 assessments.

Following our visit in May 2026, we had significant concerns about the cleanliness of the service. Floors in all areas of the department were generally unclean, with significant amounts of dust collecting in corners and along skirting boards. Work surfaces were often unclean. For example, we found pieces of bread on top of a resuscitation trolley. We also found many dirty and dusty pieces of equipment, such as ultrasound machines and blood glucose monitors. Probes on blood gas machines were noted to be covered in significant volumes of dried blood. Toys and chairs for children in the paediatric Emergency Department (ED) waiting area were scuffed and dirty. Sofas in multiple areas of the department had cracked and fraying covers, meaning it was not possible to clean them. Boxes meant for storing equipment in resus were dusty. Some of these concerns were relayed to us by staff, who said they had noticed long-term issues with cleanliness.

The service did not have clear oversight of cleaning processes. The service outsourced some cleaning duties to an external company. Staff members from this company operated using a work schedule rather than a signed checklist. Oversight of this cleaning was supposed to be achieved through a weekly cleaning audit, however the audit for the week we were present (12 May -18 May) showed 94.8% compliance despite the problems we identified during the assessment. It was not always clear whether certain cleaning duties were the responsibility of this external company or of ED staff. For example, the work schedule for the external cleaning company stated electrical items were cleaned daily, however ED leaders told us that this was a nursing responsibility. A volunteer within the ED also told us that they were sometimes given cleaning duties, despite this not being an official part of their role.

We were not assured that there were systems in place to prompt ED staff to complete cleaning duties allocated to them. Nursing staff were expected to sign ‘daily cleaning and checking’ sheets as a record of their cleaning. These sheets were different for different areas of the department. Some of these sheets did not prompt staff to clean, only to ‘check’ various areas and add comments. Some also did not include mobile equipment such as ECG machines or observation machines, the cleaning of which was the responsibility of nursing staff. The service did not consistently record cleaning allocated to nursing staff any other way (for example, by using green ‘I am clean’ stickers). Additionally, the nursing ‘daily cleaning and checking’ sheets were regularly incomplete or empty in majors.

Staff did not always adhere to ‘bare below the elbow’ practices, which are designed to decrease the risk of infection. We observed several staff wearing sleeves and watches. Some of these staff members were not employed by the ED and were instead from other care groups, however we did not see any ED staff members challenge these practices. We observed some ED staff walking around and opening doors with gloves on, and we observed one member of staff drop a glove on the floor and then continue to use it to remove an intravenous cannula. The service regularly completed hand hygiene audits in which senior members of staff reviewed compliance with hand hygiene policies. These took place in both the adult and paediatric areas and showed compliance rates of between 84% and 100% in the 3 months prior to our assessment.

We raised these concerns with the trust and they made immediate improvements. When we returned in June 2026, floors and surfaces were generally cleaner and less dusty. Sofas with cracked and broken covers had been removed. Equipment was visibly much cleaner than previously. The service had started using timed sign-offs for reviewing the cleanliness of patient toilets. The service had started using dated green ‘I am clean’ stickers on equipment in some areas, but this was not standardised across all areas of the department and there was still not a clear record of how mobile equipment was cleaned in majors. All staff were bare below the elbow, and the service had put posters on the walls reminding staff of the importance of this. We observed no staff walking around with gloves on. The service had removed some toys from the paediatric ED waiting area, however many of the remaining toys were still scuffed and dirty. ECG machines across the department were noted to be covered in sections of medical tape, which made cleaning difficult.

The service did not always make sure that medicines and treatments were safe and met people’s needs and preferences. People did not always receive their medicines as prescribed, the service did not employ any pharmacy staff directly, and there were issues with the service’s use of Patient Group Directions (PGDs).

There was no dedicated pharmacy service for the Emergency Department (ED). Pharmacists were instead shared with other care groups. This was not compliant with Royal College of Emergency Medicine (RCEM) guidance, which states that all emergency departments must have a dedicated pharmacist and a dedicated pharmacy technician 7 days a week. This meant clinical pharmacy service provision was reactive rather than proactive.

People did not always receive their medicines as prescribed due to medicines not being available to ED staff in a timely manner. We reviewed the records of 10 patients and saw missed and omitted doses that had been marked as not given retrospectively, due to 'drug not available'. These included antipsychotics, antidepressants, and medicines for epilepsy. This could have a negative impact on a patient’s physical or mental health. When we discussed this with the trust, we were told that some of the reasons for these omissions included medicines not being stocked, ordered medicines not being collected by porters, and staff not correctly documenting when patients refused medicine. The trust told us it had made some improvements, including stocking within the ED some of the medicines that we had identified as having been omitted.

Staff told us that they had access to digital systems that allowed them to securely view important medical information, and were therefore able to reconcile medicines that people were taking in their own home. However, patients who had prescriptions altered while in the ED did not always have their prescriptions or discharge medicines verified by a pharmacy staff member before discharge.

Patient group directions (PGDs; written instructions used to supply or administer medicines to patients without a prescription) were in place. These were used mainly by triage staff to administer medicines before a patient had been seen by a prescriber. These PGDs were in-date and regularly updated. However, they were not easily accessible on the Trust intranet. This meant that staff administering medicines using these PGDs could not check them for reference (for example, to check for exclusion criteria). We raised this with senior staff who told us that they will usually send copies of PGDs by email to individuals who use them. The service did not keep up-to-date records of which members of staff had read and were authorised to use these PGDs. We were therefore not assured that all staff using these PGDs to administer medicines had received up-to-date training and were aware of relevant updated guidance.

Controlled drugs (CDs) were stored safely and securely. They were managed appropriately in line with CD legislation. Medicines cupboards were unlocked behind a swipe access door; however senior leaders told us that this had been risk-assessed and there had been no incidents as a result.