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

The service did not have sufficient numbers of suitably qualified, competent, skilled, and experienced nursing staff. There were vacancies in various roles and there was a dependency on bank and agency staff to ensure the shifts were covered. At times shifts were run without safe levels of staffing.

Staff had training in key skills. However, training figures for paediatric basic life support were below the trust target.

The service-controlled infection risk well. Staff on wards 15, 16 and within neonates understood how to protect patients from abuse. However, on ward 14 we identified children were witness to potentially distressing incidents, including restrictive practice, which may have had an impact on their wellbeing. Due to the serious concerns about the care and treatment for one young person on ward 14, CQC made a safeguarding referral to the local authority.

Staff assessed risks to patients, acted on them and kept good care records on all wards, except for ward 14. On ward 14 we identified one child in crisis, where their individual risks were not assessed correctly or documented.

The service managed medicines well. Safety incidents were well managed and there was evidence of learning from incidents and events.

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

Children, young people, and family members told us they felt there was a positive atmosphere on 3 out of the 4 wards. They said staff spoke to them openly and honestly in relation to their child’s care and treatment. However, family members told us they felt there could be more staff on the wards.

Feedback from staff and leaders

Some staff were not up to date with all mandatory training. Data we reviewed showed a variable rate of compliance in mandatory training. The trust’s target for completion was 85%. This had been met except for manual handling training level one and paediatric basic life support. Completion rates for manual handling training were recorded as: children and young people 71.4% and neonates 60%. The service was also below its trust target for paediatric basic life support. For the children’s service and wards 14 and 15 the compliance rate was 71.4%. However, for manual handling training level 2 the service were recorded at 95.3%.

The trust told us the resuscitation team regularly reviewed the resuscitation training provision available for staff in terms of content, course structure and delivery methods.

Staff understood which events should be incident reported and knew the processes for reporting them. The trust told us learning from incidents was shared with the paediatric and neonatal teams using ‘learning from incidents’ bulletins sent to staff through email. Staff told us safety huddles were also used to communicate feedback from incidents directly to staff.

All staff were able to explain and give examples of the duty of candour, which showed they had a good understanding of when this process needed to be applied.

Processes

Staff recognised and reported incidents on the electronic reporting system. Trends and themes from incident reports were learned from and used to improve the service. The Quality Improvement Projects (QIPS) group had oversight of all the learning and reviewed trends and themes data on a quarterly basis. This review included taking account of the area in which the incident occurred, level of harm, action taken, and any lessons learned. The learning from incidents was shared directly with staff safety huddles in all clinical areas. It was also shared through email and newsletters. Teams also attended ‘hot briefs’ which acted as a mechanism to share feedback and learning from incidents quickly.

Between March and September 2024, the service saw an increase in the number of times where restrictive practice was used. Staff described this period as a difficult time on ward 14. Data showed 937 reported incidents for wards 14, 15, 16 and neonates between October 2024 and October 2025. Within that were 64 restrictive practices formally reported and 11 of those reflected the involvement of hospital security staff on ward 14. There were no incidents of restrictive practice reported for any other of the children’s areas.

The trust told us 45 cases were considered for duty of candour in the last 12 months, of which 33 incidents had duty of candour applied. The duty of candour regulation only applied to incidents where severe or moderate harm occurred. We reviewed 3 of these incidents and found no concerns in how these had been completed.

The service monitored national safety alerts. Safety updates were communicated by email to all staff.

People’s experience

Most but not all families told us staff were supportive and gave advice when required. Some families told us staff were good at providing them with information on the next steps of their child’s care and treatment. However, some families told us they had to seek out staff to find out about their child's care and treatment, and once they spoke with a member of staff families told us they provided information on the next steps of their child’s care and treatment.

Feedback from staff and leaders

Staff told us about their frustrations about not being able to instantly access detailed mental health records for children in crisis. However, we found summary notes written by Child and Adolescent Mental Health Service (CAMHS) staff were available and could be scanned onto the new system into the dedicated CAMHS section so staff could access them. Staff gave a mixed response when asked about how the new electronic patient record system which was implemented across the Trust in June 2024 was supporting them to look after children and young people, but we understood this was beginning to improve.

The service had support from the CAMHS team from the local mental health trust. Although CAMHS staff were not based on site, they joined daily crisis calls. There was a 48-hour key performance indicator for CAMHS to assess patients. This was mostly achieved.

The CAMHS team provided support to the service between 8am and 8pm daily. However, staff told us the service was difficult to access support out of hours despite the provision of an overnight coordinator.

The service had seen an increase in the number of children and young people attending who presented with eating disorders, physical and complex mental health needs. We identified there were positive relationships with the local eating disorder team, and they supported through multidisciplinary team meetings and completed assessments or supported triage.

The service had access to an electronic communication system to support nonverbal children and young people to support them to express their feelings, wants and needs. We found these systems were used regularly. However, they not always been used with the autistic young person who had been on the ward.

Staff told us the service did not have a transitions’ team for most children with long-term conditions. Transition arrangements include clinics in services for children with diabetes, epilepsy, endocrine disorders, cystic fibrosis and rheumatological conditions.

Processes

We found the service completed a self-assessment of the British Association for Performing Arts Medicine framework for the children and young people’s service. This clearly identified that 4 standards had not been met. These was a lack of specialist lead roles in the neonatal service, this included neonatal qualified specialist nurses, neonatal nurse consultant, and a discharge coordinator.

We found in this self-assessment, the last standard not achieved was funding for 1:1 nurse to baby ratio for intensive care. However, the service told us this was included in a business case for neonatal nurse staffing, and the risk had been placed on the corporate risk register.

People’s experience

Children, young people, and their families told us they felt safe and were happy in the care of staff. They also told us they felt able to raise concerns and where confident staff would address them.

Feedback from staff and leaders

Staff had a good knowledge of safeguarding processes and knew how to recognise abuse or prevent it from occurring. However, during our inspection on ward 14 we raised a safeguarding alert, which was shared with the local authority. This was raised because of our observations related to the behavioural distress, and the care and treatment of a child in crisis. We were also concerned about the direct impact on other children and staff on the ward.

We noted several repeated incidents on ward 14 included damage to the environment, aggression towards staff, restrictive practice, and inappropriate language from the young people who were on ward 14. We identified one child in crisis who was not getting the holistic input required to support their individual needs.

The trust target for safeguarding training was set at 90%. Compliance data for the ward areas showed staff were compliant with safeguarding children's level 1, 2 and 3 and safeguarding adults' level 1 and 2 training and achieved the trust target. However, compliance for safeguarding adults' level 3 training was 87% which fell just short of the trust target. For the neonatal ward both safeguarding adults' level 2 and 3 were less than 90% compliance and 12 staff were not updated in their training.

The service had 4 named safeguarding leads who had received level 4 safeguarding training.

The senior staff told us there had been no missed safeguarding opportunities identified from serious case reviews between February and September 2024.

However, staff did express concerns the new patient record system was not capable of flagging ongoing or past safeguarding concerns for children.

The new electronic patient record (EPR) system had a safeguarding triage tool which was completed upon admission. At the time of inspection an audit had been carried out on a sample of 26 records in June 2024. The audit findings showed only 6 (23%) forms were fully completed. A further sample was reviewed in July 2024 and demonstrated a marked improvement with 72% of the forms fully completed. Senior staff were monitoring compliance and provided staff with support to ensure the necessary improvements were made.

The service had a safeguarding team who were accessible to all staff from Monday to Friday 7am to 6pm. The clinical site team and matrons were also able to provide support out of hours to staff. The trust intranet also provided staff with the most up to date policies, procedures and contact details for the local authority.

Staff were provided with learning disabilities and autism training at level 1 and 2. Compliance data for level 1 training was recorded at 86.3 % and 10% for level 2. Leaders recognised the low levels of compliance and had developed an action plan to ensure compliance with the NHS England requirement of 30% of all Trust staff were trained to level 1 or 2 by March 2025.

Processes

There were systems and process to ensure children and young people were protected from the risk of abuse. The service had implemented a new electronic patient record system supported an auditing process. This ensured the safeguarding triage tool was being completed to assist staff considering safeguarding risks.

The August 2024 board meeting minutes indicated the highest reported reasons for referrals to Children’s Social Care was for emotional abuse (62%) followed by neglect (32%). The number of referrals completed between February 2024 and August 2024 was consistent with previous reporting periods with approximately 400 referrals completed.

However, staff told us the new ERP system did not indicate a marker or flag on safeguarding records for patients who might be considered a safeguarding risk. We were told this was being addressed in order to enable this flag to be evident for staff.

The service had a system to monitor all young people between the ages of 16 and 17 years who were placed on adult wards. This was monitored every morning, and at the time of the assessment there were no 16 or 17year olds placed on adult wards.

Data showed between 29% and 38% of staff from November 2023 to May 2024 who had taken part in safeguarding 1:1 session. The trust told us “These sessions are optional and offered to staff to enable access to advice and support from peers, managers or named and designated professionals through supervision. They are not a mandatory requirement for staff.”

The department’s safeguarding policy was up to date and reflected intercollegiate guidance.

People’s experience

We spoke with 14 children and young people and families during the inspection. Their feedback about the care and treatment they received was mostly positive. Some families told us they sometimes experience a long wait to speak to a member of staff. However, they also told us when they managed to speak to staff, they took time to listen and talk through any concerns/risks raised.

Patients and families told us their consent for treatment was sought before any care or intervention occurred. They told us they were actively involved in the care planning and risk assessment process which ensured a person centred and individualised assessment was completed for each child.

Feedback from staff and leaders

We found good interpersonal relationships between staff groups which had a positive impact on multidisciplinary care.

However, staff did express concern about their ability to provide individualised care to children in crisis on ward 14 because of the complex nature of their needs and the unsuitability of the care setting. Staff told us a different skill set was required to care for these children from the skills typically required in an acute hospital setting.

Staff worked well together to ensure the care delivered was in line with national guidance, risk assessed and tailored to meet individual need. Staff could tell us about the various systems and process they used to ensure individual risks were identified and mitigated throughout a child’s stay.

Processes

Children in crisis did not always have their individual risks assessed or mitigated during their admission. The service had seen an increase in the number of children in crisis requiring admission in the last 12 months. These children were usually admitted to ward 14. During our inspection we identified one child on this ward who did not have their individual needs risks assessed or appropriately mitigated. However, we acknowledge this was a complex case whereby staff were not always able to access information held by other organisations to support the completion of a full care plan. This had an impact on the child but also the other children on the ward who were exposed to threatening behaviour, damage to the environment, aggression towards staff and restrictive practice. The challenging behaviour had resulted in hospital security staff being placed on the ward in an attempt to manage the situation. Restrictive practice was considered as a last resort. However, this approach was unsupported by a care plan or escalation plan to guide staff in how this should be safely managed or when it should be carried out. We also noted these incidents of restrictive practice were not formally reported.

Evidence showed the police had attended ward 14 on a number of occasions due to a young person’s aggression and property damage. However, we found no formal record of the police attendance, the intervention or actions taken in the medical records we viewed.

The service provided us with a ligature risk assessment which had been completed for ward 14, which indicated the area was ligature free. We noted the date of the ligature ward 14 action plan stated “2024” but it was unclear apart from the year 2024 when it was carried out. The trust had undertaken a refurbishment in the bathroom to remove the ligature risks. However, during the assessment we noted there were still ligature risks on ward 14 which we raised with the service at the time of assessment.

The service had self-harm and ligature care plans. However, these were not completed for one child in crisis on ward 14. We found a lack of support from senior managers for the ward manager and ward staff and senior oversight of this high-risk patient cohort during our visit.

The trust had an abduction policy which was developed for the women and children’s group. In addition to this the trust had a missing persons policy which incorporated any patient going missing from any clinical inpatient setting. This policy also covered children who went missing from the age of 16 years old. Senior staff told us they had a procedure for baby, infant and child abduction or a missing child. Staff used a nationally recognised tool to identify children or young people at risk of deterioration and escalated them appropriately. The staff used the Paediatric Early Warning Score (PEWS) system when monitoring patients’ vital signs and signs of deterioration. Data showed from April to September 2024 the PEWS were 100% completed.

Sepsis training was provided to all staff groups supporting children and young people. For the months of June, July, and August 2024 staff were 100% compliant.

The trust ran a themed education month with a focus on Sepsis. ‘Sepsis September’ provided staff with simple quick reference guides and teaching was delivered in clinical areas to support staff.

Most but not all staff had completed resuscitation training. Compliance levels for the ward areas were below the trust target with the exception of the neonatal unit which exceeded the trust target.

Automated external defibrillator (AED) training was also provided to staff. Training compliance on wards 14,15 and the high dependency unity (HDU) was below the trust target. The neonatal unit again exceeded the trust target for this training.

Senior staff told us the reduction in compliance related to on the need to focus on the implementation of the new electronic patient record (EPR) system training to ensure a successful roll out of the technology. The trust leadership team told us there was a 3-month improvement plan for mandatory training compliance, and oversight would be provided through their performance management framework.

Senior staff told us they completed ‘hot de-briefs.’ This was where debriefings with staff took place within the hour or the same shift when an incident had occurred. However, some staff told us these did not always take place in a timely manner, or at all.

When children and young people with autism or learning disabilities came in for a planned admission the service was adapted to meet their needs and minimise their individual risks. Any social care staff working with the child stayed with them to ensure good advocacy and consistency. These children came into the service with their care passports which helped ward staff understand their care needs and individual risks. The ward had a range of different communication aids and additional support was provided by the learning disabilities lead nurse.

The service offered a chaperone service if required or requested if the patient required additional support.

People’s experience

Patients and their families told us they were cared for in a clean and tidy environment. Patients and families told us they felt the environment was suitable for children and young people. Ward had dedicated play areas which had a range of age-appropriate toys. Parents told us call bells worked and staff responded in a timely manner.

Feedback from staff and leaders

Staff told us they worked in a suitable environment with access to the necessary equipment to be able to meet the needs of the children they cared for. Medical equipment was well maintained and when something got broken it was quickly repaired or replaced. There was a good relationship with the estates team who responded quickly when staff logged a repair request.

Observation

There was a risk of unauthorised entry to ward areas with ‘tailgating’ (following another person who had authorised access) and unchallenged entry. The wards and neonatal unit had secure entrances with intercom and a CCTV. Staff had a swipe card to be able to enter and patients/families had to press the intercom to be able to gain access. The wards were secure unless people were able to follow others who had been permitted access. We were able to enter the ward ‘tailgating’ family members, as there were no staff at the main door leading from the corridor and our entry was not challenged.

On neonates we found the breastmilk fridge was unlocked and bottles containing milk were not labelled in line with evidence-based guidance. However, two risks were identified which were tampering either accidentally or intentionally with the milk. Also, the risk mothers could potentially pick up the wrong baby milk and feed their baby. These were highlighted to the clinical team and immediate action was taken to address them.

The service had enough resuscitation trolleys with suitable equipment available to support staff manage a medical emergency. However, we found the routine safety check process was not carried out in line with trust policy. On ward 14 and 16, on 2 resuscitation trolleys, calibration stickers on the electrical extension leads to the equipment stated 2022 and 2023, which we raised with staff while on site to address and staff told us they would action immediately.

The design and layout of the department followed national guidance. However, in ward 14 there were still visible ligature risks identified. Which the trust told us the ligature risk assessment provided for ward 14 identified the ligature points, risks and mitigations in place to minimise the risk.

The wards had areas for children to be able to play and there was an education room where school lessons could take place. The service employed play coordinators who supported the development, emotional wellbeing, and therapeutic needs of children through structured and purposeful play.

The service had an incident flow chart, which explained what happened if there was a fire. Although staff knew how to respond in the event of a fire, this had not been practised. Ward managers said they would discuss after our assessment what more could be done to consider fire safety.

All corridors and fire exits were kept clear and clutter free. We saw windows were secured, which meant children/young people could not open them. Fire extinguishers and oxygen cylinders were secured and tagged where required.

The service monitored equipment on the maintenance log, which reported what had been replaced or repaired. All sharp bins were signed, dated, and stored correctly. Staff disposed of clinical waste safely and in accordance with correct separation.

Processes

The trust processed national patient safety alerts and drew up actions against the alert recommendations. Each alert had an identified lead, and the action plan was approved by the Chief Medical Officer before submission. Once this was completed this was escalated to staff and the wards to action. The trust shared examples of where this had taken place, and staff had addressed recommendations.

Feedback from staff and leaders

Nursing staff told us they did not have enough staff due to high levels of sickness and current vacancy levels. The service was using agency and bank staff to fill the shifts. Staff told us there were times where there were not enough staff on shift, staff told us this left them feeling unsafe. They told us they would escalate their concerns by completing an incident form. The staff vacancy rate for the service in March 2024 was 7.5%, and this increased to 9.9% by July 2024, but started to reduce to 8.6% for August 2024. Staff were aware the trust was undertaking a current recruitment drive to fill the vacancies.

Medical staff told us the service met all 10 of the Royal Collage standards for medical staffing and the optimal arrangements for neonatal intensive care unit guidance.

Observation

We observed ward rounds where both doctors and nurses discussed each patient and the next step of their care and treatment.

There were enough staff on the wards at the time of the assessment but there were agency staff working in the service to cover vacancies and sickness.

We saw staff interacting with children, young people, and their families. Staff gave patients and their families sufficient time to talk and ask any questions they may have.

We noted the staff notice boards indicated the planned staffing with the actual staffing levels for both days and nights, which identified the staffing on shift and there was a nurse in charge on each shift.

Processes

The Trust told us “Staffing levels are reviewed three times a day to ensure correct skill mix of staff is available based on patient dependency. The trust holds twice-daily safer staffing meetings to discuss staffing levels and any ongoing concerns. A safer staffing template is completed during these meetings and escalated as needed. Neonatal nurse staffing data is also reported into the West Midlands Neonatal Operational Delivery group daily though the Neonatal ‘Sit rep.” However, managers knew the vacancy levels and worked to reduce them. Managers also told us sickness levels were high at the time of assessment and understood the reasons behind this. Staffing numbers were routinely monitored and were presented to the trust board.

Staff sickness between March and August 2024 increased. In March 2024, the sickness levels were 3.1%, and by August they had increased to 6%.

The service used regular bank and agency staff who worked regular on the wards to manage staff shortages. Bank staff use for April 2024 was 0.6%, by July 2024 this had increased to 9%. In April 2024 usage had increased to 10%, with July being the highest at 18%. This then reduced to 11% for September 2024.

The service did not have a sufficient number of qualified neonatal nurses. Current ‘qualified in specialty’ (QIS) trained nurses within neonates was 48.96 whole time equivalent (WTE) or 63.4%. The nurse vacancy rate was 8.87 WTE or 10.2%. This was below the British Association of Perinatal Medicine (BAPM) guidelines recommended standard of 70%. The trust stated these staffing concerns were placed on the risk register and staff training would be completed by March 2025.

All the consultants working in the service were qualified paediatricians. The service met the Royal College of Paediatrics and Child Health (RCPCH) standard for consultant over. The neonatal consultants were resident on the until from 9.am to 9pm, 7 days a week. The paediatric consultants were resident from 9am to 10pm, Monday to Friday, and on Saturdays and Sundays were resident until 6.30pm. Outside of these times the consultants were available to return to support the service and return within 30 minutes. The service also employed 3 resident doctors (middle grade registrars) to provide 24-hour care. Two supporting paediatrics and one supporting neonatology.

The trust had 2 registered learning disability nurses and 2 registered adult nurses who worked across the paediatric service. The team also had access to the support of a learning disabilities and adolescent lead nurse and play coordinators.

Staff told us mental health training was not mandatory but was available. They also told us they felt there was a lack of mental health trained staff available on ward 14 which in recent times saw an increase in the number of patients presenting with a history of complex mental health conditions. Only 61% of the staff team had received CAMHS training at the time of our inspection.

Senior staff told us the adolescent lead offered 1:1 clinical supervision following challenging or upsetting incidents. However, when we spoke with staff on ward 14, which supported older children, they told us these were not consistently offered. They also told us staff morale was very low on the ward.

During the assessment, a mother was experiencing difficulty in breast feeding. We spoke with a nurse who sought support from staff within the maternity unit to help support the patient and give advice in relation to breast feeding. The trust had breastfeeding coordinators who supported the maternity service and staff in children’s services could make referrals for support when needed.

Hospital security staff were employed through a third-party facilities management provider. They did not undertake any specific mental health awareness training. The trust has told us “Since the inspection we have been informed that half the workforce have been trained with plans in place to train the remaining staff member.” This was identified as a risk to the service given the interventions witnessed on ward 14.

While the service did have a TRiM (Trauma Risk Management) training programme it was paused at the time of our assessment. This was due to the members of staff moving to new roles outside of the trust. Leaders told us there was a plan to reinstate TRiM or another similar psychological support programme as part of the trust’s wellbeing delivery plan. The new programme proposal was due to be approved at the people committee in early 2025.

Feedback from staff and leaders

Staff had a good understanding of infection prevention and control practice. They also told us they participated in hand hygiene audits. The trust also provided staff with infection prevention and control training modules. There was a trust-wide infection prevention team who supported staff to mitigate the spread of health acquired infections.

The service used fabric curtains in ward cubicles and had a process to change these regularly. However, we could not locate records which showed the frequency of cleaning when requested.

Staff told us they had enough personal protective equipment which was easily accessed. Hazardous cleaning equipment was stored correctly.

Observation

Wards were visibly clean and tidy and had suitable furnishing which could be easily cleaned to minimise the risk of infection. The service employed domestic staff who kept up to date with the day-to-day cleaning. Staff completed cleaning records which identified what needed cleaning on a daily, weekly, or monthly basis.

The service had side rooms which they could use to provide patient isolation if required to prevent further spreading of infections.

We observed staff washing their hands or using hand sanitiser and this took place between seeing patients as required. Staff used gloves and aprons when needed. Bed spaces were deep cleaned between patients leaving and new admissions.

We observed parents and staff sterilising baby equipment before making bottles. The service had clear 5-step posters on display and in an easy read format in relation to hand washing techniques. The service used “I am clean stickers” which identified when equipment had last been cleaned. Staff were using personal protective equipment as required.

Processes

The infection prevention and control team completed hand hygiene observations and audits. These were scheduled quarterly and were also undertaken as required following incidents and outbreaks or where concerns were raised.

There was good compliance with catheter and cannula practice. The service completed monthly cannula and catheter audits. Checks on catheters showed a compliance rate of 98.6%. For cannulas, the compliance rate was 97.1%.

Senior staff told us during September 2024 they recognised the new electronic patient record system had impacted on the documentation of these medical devices. The infection, prevention and control team worked closely with system developers and clinical staff to determine when and where this documentation should be logged on the new system.

Hand hygiene observations had showed some shortfalls in practice. Areas for children and young people had 22 members of staff trained and validated to monitor handwashing procedures. Across the service, 499 hand hygiene opportunities had been observed from April to September 2024, with 400 of these (80%) achieving compliance being successfully completed.

People’s experience

Children and young people were supported to receive their prescribed medicines in a way that met their individual needs. Parents, carers, and patients told us they were included in discussions about their medicines, so they felt informed about what they were taking. Parents and carers told us they were given information, advice, and support about their medicines, including when there were changes made to the medicines by doctors and members of the pharmacy team.

Feedback from staff and leaders

Staff told us they knew how to contact pharmacy for advice and there were effective processes for the supply of medicines. Staff told us there was a good pharmacy presence and the pharmacy team were 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, which staff said was helpful to ensure the right medicine was administered to patients. Staff told us this had made it easier to document why medicines had been omitted.

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

Between April and September 2024, the service had administered rapid tranquilisation 29 times, due to extreme violence and aggression from a young person. Senior staff told us they used verbal de-escalation, distraction and oral medicines were offered prior to the administration of rapid tranquilisation. Post procedure observation and monitoring in line with the policy were conducted.

Observation

We observed pharmacy staff discussing medicines with patients and staff. Medicines were locked and secure with access only to authorised staff. We observed that medicines were stored safely in line with recommended practice. The use of automated electronic medicine storage units were located on every unit to support ward staff locate the correct medicine and ensure availability of medicines.

Medicines for refrigeration were stored securely at correct temperatures, with electronic central records available of maximum and minimum temperatures.

We observed members of the pharmacy team reviewing medicines and having discussions with parents and carers to check the medicines history of patients was accurate and up to date. This also included advice on how to take any new prescribed medicine.

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

Medicines for refrigeration were stored securely at correct temperatures, with electronic central records available of maximum and minimum temperatures.

Processes

There were 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 and 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 6 patients’ medicines administration records. They were well documented with route and time of medicine administration, including recording a reason if a medicine was not given. Any missed doses were flagged as a reminder until the medicine was administered which was important especially for time critical medicines. Where a ‘PRN’ (when required) medicine was administered staff recorded why it was needed. The information we looked at showed patients were receiving their medicines as prescribed.

Pharmacists were able to raise any medicine queries on a pharmacy ‘intervention form’ for medics to review. We were shown examples of how this was recorded.

Weights of patients were recorded. However, they were not documented on the patients’ electronic medicine administration records which would be useful to help support calculating weight-based medicines prescribing.

The electronic patient record had a medicine dose calculator built into the system. This was useful to support prescribing the correct dose for weight-based medicines especially in children and young people.

Venous thromboembolism (blood clot) assessments were mandatory for children over 16 years old and were 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. Any identified allergies were red flagged as a reminder.

There were effective processes for reviewing antibiotic prescribing which included documenting a reason for the antibiotic choice. A review date at 48 and 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 2 staff daily.

There was a process for managing and reporting any errors or incidents involving medicines staff were able to describe.

A pharmacist attended the ward round which was useful for identifying any planned discharges or to deal with any immediate medicine queries.