University 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

Not all staff had updated their training, including safeguarding, in line with the trust target. Most people using the service felt listened to, but this was not the experience of all people, and we were not assured all staff met the needs of patients admitted to their wards. The service did not always work well with patients and families or carers to establish and maintain safe systems of care for discharge. They did not always make sure there was continuity of care, including when people moved between different services. The service compliance for sepsis monitoring was low with no action plan provided for improvement.

However, learning from incidents was evident and staff managed incidents well. Staff knew what incidents required reporting and how to report them. There were processes to support staff to report and learn from incidents, duty of candour was applied where appropriate. Staff understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. They managed medicines well. Staff mostly assessed risks to patients well, acted on them and kept good care records. There were processes to ensure the service had enough staff with the right training, skills and qualifications to keep patients safe from avoidable harm.

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.

People's experience

Staff were open and honest with patients and carers and took any concerns they had seriously. We spoke with patients who told us they felt safe on the ward and that staff listened to any concerns they had and acted on requests. Patients felt supported to raise concerns and felt staff treated them with compassion and understanding.

Patients we spoke to knew who to speak to with queries about their care or treatment. There was information available for patients, families and carers on how to make a complaint.

Feedback from staff and leaders

Staff we spoke with told us that there was a positive culture based around support and learning. The service held seminars for staff to attend for example: Sickle Cell treatment, issues this patient group may be affected by and the actions taken. Staff told us that managers were open and honest, and they felt able to go to them with any concerns about safety. They felt listened to and supported and felt that action was usually taken to address any concerns they had raised.

The mandatory training for staff was comprehensive and met the needs of patients and staff. Training covered several subjects including safeguarding, ALS and recognising and responding to patients with mental health needs, learning disabilities, autism, and dementia.

The service completed mental capacity act training and Deprivation of Liberty Safeguards which was completed as part of the safeguarding training modules.

Staff knew how to report incidents and said that learning from incidents and actions were shared. They said they felt listened to by managers and were easily able to raise any concerns which were usually acted on. Managers encouraged staff to raise concerns when things went wrong.

Staff we spoke to understood the application of duty of candour and could give examples of when they would use this.

Processes

Learning from incidents and complaints resulted in changes that improved care. There was a process in place for the reporting of incidents and sharing outcomes of investigations. We saw evidence that learning from incidents was shared on the weekly safety messages, for example actions requiring staff to review the escalation process for deteriorating patients. The service also encouraged staff to suggest safety topics via an email address.

Staff had effective systems to raise concerns both formally and informally. Reports were analysed and urgent actions taken by leaders to manage or remove risks. Evidence we saw following our inspection showed that staff reported incidents. Incidents were scored from no physical harm to fatal. The majority of incidents were scored as no physical harm. The most reported incident type was implementation of care or ongoing monitoring/review, this category could include incidents like missed medication doses, delays in treatment, failure to identify deteriorating clinical conditions, or not adequately monitoring a patient's vital signs during treatment. During staff meetings we attended, the team discussed and learnt from incidents and audit outcomes. Staff felt there was an open culture, and that safety was a top priority. Compliments and complaints were also discussed at meetings.

There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Evidence we saw following our inspection showed that complaints for the service were collated and reviewed for themes and action plans put in place. In the period 1 October 2023 to 1 October 2024 the medical care service recorded 134 formal complaints. The highest number of complaints were about clinical treatment (26 complaints), appointments (15), communication (14) and admissions, discharges and transfers (14). We saw evidence that action plans had been put in place as a response to complaints for example: discussions with staff to ensure that difficult conversations were help with patients around discharge planning and capacity issues and a new template for devised for use during pre-assessment of a patient and for these actions to be discussed at the daily safety huddle.

There was a duty of candour policy which was in date and due to be reviewed in April 2025. The service had a lead investigator for the patient safety incidents, following out inspection we saw evidence that duty of candour had been applied and patients contacted.

People's experience

Most patients we spoke to felt they were kept informed of treatment plans, discharge plans and referrals. They said they had opportunities to speak to doctors and consultants about their care. Plans were made with occupational therapists for ongoing support and assessments of needs for discharge and ongoing care. Patients said they knew who to contact about concerns or if they felt their condition was worsening. However, some patients and family members we spoke to said they were not always informed of the next steps, especially where the patient had complex or multiple needs. One family member explained that despite complaining to the patient advice and liaison (PALS) team and requesting information on their loved one's condition, treatment, and ongoing care the responses had been poor. They explained that they were needed to support the patient at key consultations but had not been informed of all meetings. The trust stated improvements had been made to its PALS process and was directing more informal concerns and issues to the ward staff to manage locally.

Feedback from staff and leaders

Consultants led daily ward rounds on all wards, including weekends. Patients were reviewed by consultants depending on the care pathway. Staff we spoke to said they could call for support from doctors and other disciplines, including mental health services and diagnostic testing.

Many patients' discharges were done straight from the ward rather than transferring the patient to the discharge lounge and their next steps of care being coordinated by another member of staff. This was positive for the patient journey as it meant that the nursing staff who have been involved with the patient's care during their stay on the ward were able to plan their discharge. However, a member of the nursing team needed time and resources for this planning therefore adding an extra task to their workload and also these discharges were not always successful.

Bed managers supported the flow of patients within the departments and gave regular updates to staff. The service had a discharge lounge which was used for patients awaiting discharge. The service did not complete any discharges overnight.

Occupational therapy teams attended wards to talk to patients who needed support and assess their ongoing care needs, for example with mobility and or changes in cognition. Staff attended the ward rounds and shared information about patients and helping plan discharges. As part of the `Improving Lives' work, patients could be seen and assessed in their own homes by the occupational therapy teams to prevent further admissions to hospital and support patients to make changes to improve their health.

Staff on the same day emergency care (SDEC) unit told us they had access to the rapid emergency assessment care team (REACT) which comprised of physiotherapists, occupational therapists, and therapy assistants. This team worked with the acute frailty unit (AFU) and medical assessment unit (MAU) to prevent people needing to be admitted to wards and being supported in their homes.

Feedback from partners

The service had systems to help care for patients in need of additional support or specialist intervention. The service had good links with the local authority social service teams and staff were able to give examples of referrals to these services and the positive outcomes for patients and their families.

There were processes to communicate all relevant safety alerts within the department, information was shared through emails, huddles, ward meetings, board meetings and clinical governance meetings.

Processes

There were processes to keep patients safe. However, at the time of our assessment there was a lack of assurance in the service that processes managing discharges were effective. Many patients records we viewed did not contain evidence of discharge planning. We explained this concern to the trust at the time of our inspection. The electronic patient record did not allow the service to accurately record failed discharges and the reasons for analysis. However, we were provided with information that all pathway failed discharges were discussed and reviewed in local meetings and flow huddles. Since our assessment, the service had implemented a process for tracking failed discharges. The service was using a `lost discharge review document' to discuss the status of discharges, but patient records were not capturing the information effectively at the time. Staff we spoke to told us that most failed discharges were due to there being no social services ongoing care packages arranged, delays with take-home medication, and patient transport delays.

The service had good oversight of the patients who were `boarding' patients or medical outliers. They were discussed at the daily safer staffing meeting which was held twice a day. These were patients who were on wards different from the speciality for their condition. For example, a neurosurgery patient on a neurology medical ward (known as an outlier patient) or a patient who had been placed on a ward to help ease the patient flow in another department such as the emergency department (also known as a `boarding' patient). The needs of these patients were discussed and the responsibility of medical staff for oversight of these patients was agreed. The service had a standard operating procedure to monitor these patients. We were provided with evidence of completed risk assessments for patients boarding or medical outliers at the time of our visit. The risk assessments had been completed to ensure the staff had access to emergency equipment, and that they were safe in the environment.

At board round we observed discussions on information to be sent to patients' GP surgeries and details of their care and/or ongoing treatment to be included in the letters was agreed.

People's experience

Patients we spoke to told us consent to treatment had been discussed with them and procedures explained to them. Staff clearly recorded consent in the patients' records.

Feedback from staff and leaders

Staff received safeguarding training for children and adults. Compliance with safeguarding adults level 2 was 91% and for safeguarding children at level 3 was 100%. However, completion rates for safeguarding adults level 3 were 69% and safeguarding adults level 1 were 84% and below the trust target of 90%. The evidence provided following our assessment showed the service had made 135 safeguarding referrals in the period from October 2023 to September 2024. The highest number of referrals, 63, were made by the care of the elderly teams and the main categories of abuse identified were neglect and self-neglect. Therefore, the safeguarding training and awareness for staff in these areas was of significant importance.

Staff knew how to identify adults and children at risk of, or suffering, significant harm and worked with other agencies to protect them. Staff we spoke to could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. They were able to describe the different forms of abuse, the indicators of abuse and the actions they would take. Staff were able to give examples of times when they had made safeguarding referrals and the outcomes. Staff told us they would gain patients consent prior to referrals for social services support being made.

Staff we spoke to said they received and kept up to date with training in the Mental Capacity Act and Deprivation of Liberty Safeguards. However, this training was completed as part of the safeguarding course and the service had not met the trust's target of 90% completion. Staff could identify the safeguarding leads were for the service and the contact information for the leads was visible on the wards and available on the trust intranet. Staff could describe how and when to assess whether a patient had the capacity to make decisions about their care. Staff we spoke to demonstrated a good knowledge of how to assess patients and that enhanced observation charts were used where needed for a patient.

Staff were able to explain the consent process to us and explain the trust policy. When patients could not give consent, staff made decisions in their best interest, taking into account patients' wishes, culture and traditions.

Processes

The service had a safeguarding children and adults' policy, this was in date and had been reviewed, the policy was available for staff to view on the trust intranet.

Staff could describe and knew how to access the policy and get advice on Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). We saw the mental capacity act policy was followed on the wards we visited. Patient notes we reviewed showed MCA forms and DoLS forms were completed appropriately.

We saw appropriate consent forms were used for patients who lacked capacity to consent but were undergoing procedures, such as in the endoscopy department. Patient files we reviewed showed that consent had been obtained, discussed, and reviewed.

People's Experience

Patients we spoke to said their treatment had been explained to them and tests results and further treatment discussed, risks of procedures had been explained to them and discussions had been had about aftercare. They said they felt able to ask questions and express concerns. Communication styles had been adapted to help them understand.

Family members and carers we spoke to said they had been kept informed about their loved one’s treatment.

Patients and their families knew who to contact if they were concerned about a deterioration in their or their loved one’s condition.

Feedback from staff and leaders

Staff completed and updated risk assessments for patients. Staff took action to minimise risks to patients. Staff used the national early warning score (NEWS2) to identify deteriorating patients and escalated any concerns to the appropriate clinical lead. Records we reviewed showed that NEWS2 score had been recorded accurately and reassessed as required. Staff completed mandatory training which included sepsis and blood transfusion. Falls assessments had also been completed and staff we spoke to told us the electronic patient record triggered completion of assessments for patients such as risk of falls assessments, observations and canula checks.

We attended the ward handover huddle which took place at the start of each day, we observed that staff shared key information to keep patients safe for example, risks such as falls assessments, patient mobility, any changes in observations for example increased blood pressure, special diets, patients with a do not resuscitate order, and allergies.

We observed a ward drug round and staff prioritised patients time sensitive medications first as generally these medications will need to be taken at the same time each day for example medication for Parkinson’s disease. Staff on the round checked patients’ identification wrist bands against the information held on electronic patient record. Staff checked if patients had any allergies and explained any changes in medication to the patients, such as different doses. Patients were asked if they would prefer certain medications (where available) in a different route, for example as a solution rather than as a tablet.

Patients who were on wards different from the speciality for their condition, for example, a surgical patient on a medical ward (known as a medical outlier patient) or a patient who has been placed on a ward to help ease the patient flow in another department (also known as a boarding patient) were seen by a medical consultant for their speciality. Nursing staff told us they checked daily to ensure these patients had been seen by the doctor or consultant for their speciality.

If staff were concerned about a patient’s mental health through access to specialist mental health support based on site, this was available 24 hours a day. This meant they could arrange for psychosocial assessments and risk assessments for patients thought to be at risk of self-harm or suicide.

Staff received training in conflict resolution techniques and told us they felt equipped to manage patients if they became frustrated.

Processes

We found that individual risks were not always adequately assessed, while the service had a process for assessing patients for sepsis, evidence we saw from audits carried out showed a compliance of 48%, 75% and 76% for June, July, and August 2024, respectively. We did not receive an action plan for improvement on these scores. However, we were made aware of improvement initiatives such as ‘Sepsis September’ which saw over 150 staff receive training on using the sepsis elements of the new electronic patient record.

The service had processes for auditing the completion of national early warning scores (NEWS2) and evidence we saw for February to July 2024 showed that these had been completed above 96% of the time and all medical wards had achieved the trust Ward Accreditation Audit, for Standard 9 (recognising the deteriorating patient).

The service had the recommended policies for managing risks including but not limited to deteriorating patient process and policy, mental health act policy and sedation policy. These were comprehensive and in date.

The endoscopy service risk assessed patients on admission based on clinical need and patient choice. If they chose, they could be sedated during their procedure.

People's Experience

Patients told us that they felt cared for and safe whilst they were visiting the service. All patients had call bells within reach, and we saw that staff responded quickly when called. The endoscopy department operated a mixed female and male appointment list but had a separate male and female waiting room and recovery room.

Feedback from staff and leaders

All staff told us they had access to suitable amounts of equipment to enable them to complete their role. Equipment was well maintained and regularly serviced to ensure patients were kept safe. Staff carried out daily checks of specialist equipment. The service had suitable facilities to meet the needs of patients’ families.

Observation

The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use them. Staff managed clinical waste well.

Ward layouts were similar on each floor. An entrance led to the ward; there was a main nurse station with two bays and a ward area leading off to the left and right with a further two bays and a number of side rooms on each ward area. There were mixed sex wards, with single sex bays. Each bay had five or six beds and a patient washroom and were compliant for meeting the national standard of eliminating mixed sex accommodation, as patients did not need to pass through other areas to access them. There were washrooms and sinks available on the ward. Some bays had an extra patient bed for boarding patients, these had access to call bells within reach and emergency equipment.”

On entry to the ward the nurse in charge, consultant and matron information was displayed for staff and members of the public to identify the senior staff on the ward. Each patient bay had a sign which displayed the name of the nurse responsible for the care of the patient. Patient safety boards were used on the wards and displayed appropriate information such as risks,safeguarding or discharge information but these were kept to a minimum.

The wards were visibly clean and tidy and mainly free from only necessary equipment in the clinical areas. However, in one ward area we observed equipment stored in a patient bathroom, this could be a trip hazard for patients or become contaminated. This equipment was moved to an equipment storage area later in the day.

The service had enough resuscitation trolleys which were all clean and tagged and regular daily checks were all completed. All doors to wards had a security system and we saw that patients, carers, and staff without a pass were appropriately challenged on requesting entry to wards. The wards had non-slip flooring which was in good condition.

Records and files were stored securely and not accessible by anyone other than staff working at the service.

The wards had access to bariatric equipment. The service had a sluice room which was clean and tidy. There were fire extinguishers which had been checked and were in date. These were placed in key areas and fire doors were free from obstruction and kept closed.

Ward noticeboards displayed information for staff, for example sepsis awareness, catheter care. There was also information with feedback and action from incidents such as high potassium levels checking.

During our assessment we observed staff responding to an emergency alert for a patient. They reacted quickly and effectively and took appropriate actions. During the emergency staff were able to access the equipment needed, for example the crash trolley and oxygen.

Processes

There were effective processes to maintain a safe environment. There was a policy for decontamination of medical devices including surgical instruments, flexible endoscopes, and decontamination equipment. The policy explained staff responsibilities, including not re­using medical devices designed for single use only and the use of detergents and disinfectants. The policy was reviewed and in date. We checked 10 pieces of equipment, and an electrical safety testing programme had been completed in line with guidelines. Other equipment checks had also been completed including fridges and resus trolley equipment. The leaders on the ward held water safety meetings and decontamination meetings.

The service completed a monthly audit program of environmental and safety checks. Infection prevention and Control (IPC) audits included hand hygiene, national cleaning standards, cannula compliance and urinary catheter compliance. The model for measuring these standards was based on the World Health Organisation 5 moments tool. Specific staff were trained by the IPC team for completing audits and outcomes of audits were shared via weekly IPC safety huddle.

Data for the audit program for environmental and safety checks we saw following our inspection showed all areas had a combined audit score above 94%. Minutes from team meetings we saw following our assessment showed that IPC audits and actions were discussed with staff.

The endoscopy service had accreditation from the Joint Advisory Group on GI Endoscopy, this was in date and evidence we saw following our assessment showed this was due for renewal in 2027.

People's experience

People we spoke to said they felt supported to understand and manage any risks. They said that staff were very busy but that they responded quickly to requests and were available to help.

Feedback from staff and leaders

The service had enough nursing, medical and support staff with the right qualifications, skills, training, and experience to keep patients safe from avoidable harm and to provide the right

care and treatment. Managers calculated and reviewed the number and grade of nurse and healthcare assistants needed for each shift in accordance with national guidance. The ward managers could adjust staffing levels daily according to the needs of the patients.

Staff we spoke to said that when bank staff were used these were mostly regular staff who know the service and the wards. They felt that the staffing levels were safe for the majority of the time and generally any reduced staff was due to sickness, and they would be supported from other areas.

The service had an average vacancy rate of 7% for the 6-month period from March 2024 to August 2024. This was below the trust target of 10% with the lowest rate being in August 2024 of 2.4%. However, some specialties had higher vacancy rates above the trust target of 10% and these were monitored by managers and any gaps covered using bank or agency staff.

The service had low sickness levels which averaged 0.68% between March 2024 and August 2024. Staff absences were mostly covered with existing staff, staff from other wards or bank staff. Managers limited their use of bank and agency staff and requested staff familiar with their service. Managers made sure all bank and agency staff had a full induction and understood the service. The gaps in the resident doctor rota were covered primarily by locum shifts, or if needed consultants who worked within the hospital would cover shifts.

The service always had a consultant on call during evenings and weekends, and medical patients had a review by a consultant daily. Staff said they had always been able to reach a consultant for advice, or they had attended the ward if needed.

Observation

We attended the safer staffing meeting during our assessment, the meeting was attended by matrons from each directorate across the trust. At the meeting staff levels were discussed and any requirements for bank or agency staffing needs were reviewed. The number of boarding patients were discussed at this meeting; these patients were identified to ensure that their treatment was reviewed daily but the appropriate clinicians and that ward staff were aware of the patient's needs. Any patients in need of 1 to 1 nursing were also discussed and resources allocated. Ward managers were able to allocate staffing based on the needs and acuity of their patients. If ward managers were not able to mitigate their own staffing issues this would be discussed at the safe staffing meeting and actions taken such as moving staff from other areas.

Processes

Not all staff were meeting the target for all mandatory training to be updated. Managers monitored mandatory training and alerted staff when they needed to update their training. However, in 13 out of the 21 mandatory training modules the service had not met the trust's target of 90% for updating this training. For example, recognising and responding to patients with mental health needs, learning disabilities, autism, and dementia had a completion rate of 70%, hand hygiene 71%, in-hospital resuscitation 72% and advanced life support (ALS) 83%.

The service managers monitored staff vacancies and sickness through the group management reviews and reported improvements or staffing risks to the trust board.

The appraisal rate for staff was 78%. The service told us that the training and release of their new electronic patient record system had impacted on appraisal compliance levels from February 2024 June 2024. They had a 3-month improvement plan for appraisal compliance which was reviewed monthly.

People’s experience

Patients told us they felt the environment was visibly clean and that they had observed staff following the infection prevention control procedures.

Feedback from staff and leaders

The service performed well for cleanliness. Data from audits we saw following our inspection showed areas had a combined average audit score of 97.7% or over for IPC. The service used the National Cleaning Standard (NCS 2021) audit. The audit was completed by clinical, domestic staff and estates staff. An audit report was distributed to senior leaders and governance groups for outcomes and actions to be taken. The service had a lead for infection prevention and control staff we spoke to were able to identify the lead and said advice and information was easily accessible.

Observation

The wards were visibly clean and tidy and mainly free from only necessary equipment in the clinical areas. There was access to handwashing facilities and hand gel in all areas we visited. We saw staff using the handwashing facilities and gel as required. There was personal protective equipment available, and we observed staff using this appropriately. During our assessment we saw staff cleaning wards and the cleaning schedules were signed and up to date. We observed staff using ‘I am clean’ stickers to show equipment had been cleaned after use.

Clinical waste was managed well and disposed of in line with current relevant national guidance.

Processes

There was a policy for decontamination of medical devices including surgical instruments and flexible endoscopes. The policy included staff responsibilities, on not re-using medical devices designed for single use only and the use of detergents and disinfectants. The policy was reviewed and in date. The service undertook IPC audits and the minutes we saw following our assessment showed IPC was discussed at staff meetings.

People’s experience

People were supported to receive their prescribed medicines in a way that met their individual needs. People told us that they were included in discussions about their medicines, so they felt informed about what they were taking. People told us they were given information, advice and support about their medicines including when there were changes made to their medicines by doctors and members of the pharmacy team. One patient we spoke to told us ‘’They are all amazing and so wonderful.”

Feedback from staff and leaders

Staff told us that they knew how to contact pharmacy for advice and there were effective processes for the supply of medicines. Staff knew who the ward pharmacist and pharmacy technicians were.

Staff told us there was a good pharmacy presence and the pharmacy department was available to support them with managing medicine processes such as ordering and receiving medicines. A new electronic prescribing medicine administration system had been in operation since June 2024. Staff said this was helpful and supportive to ensure the right medicine was administered to patients and it was easier to document why medicines had been omitted.

Staff told us they had access to relevant medicine policies, procedures, and guidelines. Staff told us they had good access to pharmacy advice, emergency medicines and critical medicines out of hours.

Staff in the oncology ward told us there had been improvements on checking medicines at discharge to ensure patients had all their prescribed medicines.

Staff in the discharge lounge ensured patients medicines were available when they were discharged. The recent introduction of a local ambulance service member of staff acted as a liaison between the patient transport service and the discharge lounge.

Observation

Medicines were not always stored safely in line with recommended practice. Medicines were not always managed safely on the Medical Assessment Unit. We observed some untidy and chaotic arrangements in the clean utility room, where medicines were stored. We saw loose tablets dropped on the floor which had not been picked up and disposed of safely. There was a lack of oversight and individual staff responsibility to ensure that medicines were stored and managed safely.

We observed pharmacy staff discussing medicines with patients and staff. We observed that medicines were locked and secure. We observed members of the pharmacy team having discussions with people to check their medicine history was accurate and up to date. We observed clinical checks being undertaken by clinical pharmacists and updating patient medicine records as part of medicines reconciliation (the process of gathering a complete list of people’s prescribed medicines) to ensure people did not go without medicines when admitted to the ward. Any discrepancies or medicine issues were successfully resolved and recorded to ensure the effective continuation of treatment.

Medicines for discharge were screened by clinical pharmacists and checked for accuracy.

Medicines storage was locked and secure with access only to authorised staff. Automated electronic medicine storage units were located on every ward to support staff locate the correct medicine and ensure availability of medicines.

Resuscitation medicines required in an emergency were stored safely in tamper-evident trolleys which followed Resuscitation Council (UK) guidance. We observed that staff recorded safety checks to ensure the medicines were safe to use.

Medicines for refrigeration were stored securely with electronic central records available of maximum and minimum temperatures to ensure the medicines were stored safely.

Processes

There were effective processes to ensure people received their medicines as prescribed. Medicine administration records were well documented, including giving a reason if a medicine had not been administered. An annual medicines management and medicines optimisation audit was undertaken between February to May 2024 for the safe and secure handling of medicines. Recommendations were given to wards where actions and improvements were needed to ensure the safe management of medicines.

We reviewed five people’s medicines administration records. They were well documented with route and time of administration, including recording a reason if a medicine was not given. Any missed doses were flagged as a reminder until the medicine was administered. Where a ‘PRN’ (when required) medicine was administered staff recorded why it was needed. The information we looked at showed people were receiving their medicines as prescribed.

Patients’ weights were recorded on the patient’s electronic patient record (EPR) as part of the secondary assessment. That information is automatically pulled through to the patient’s drug chart when updated in the EPR.

Venous thromboembolism (VTE) assessments were mandatory and had been completed by the medical team.

Allergies were highlighted and medicines could be prescribed safely. The allergy status of patients was recorded on all medicine records seen.

There were effective processes for reviewing antibiotic prescribing which included documenting a reason for the antibiotic choice. A review date at 48-72 hours after initiation of treatment was highlighted on medicine charts.

Controlled drugs (CDs are medicines requiring more control due to their potential for abuse) were stored safely and securely with access restricted to authorised staff. Checks were undertaken and recorded by two staff daily. Checks of CDs showed that they were within date and stock balances were accurate.

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

A pharmacist attended the Acute Medicine Governance huddle meetings from Monday to Friday to pick up any learning actions or medicine issues such as missed doses or medicine shortages. This was used as an opportunity for training and education.