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

Staff did not always have time to report things when they went wrong. There was a developing culture of accepting the department was under such high levels of demand that patients often had to wait for many hours to receive treatment. Nursing staff told us some tasks were being rushed to ensure work was completed. However, when things went wrong and were reported, events were investigated, and learning was embedded to improve practice.

The environment was not set up to allow staff to safely manage all patients when capacity and demand was exceptionally high. The waiting area was too small for the number of patients waiting to be seen. It was too often very overcrowded and there were not enough seats for everyone to sit down or for patients to be accompanied by relatives during the busiest times.

Some staff had not undertaken safeguarding training at the level required for their roles. However, staff were clinically competent and had the right skills to meet people's needs. They had the opportunity to learn and gain experience. There were systems for appropriate and safe handling of medicines to ensure people were given their medicines as prescribed.

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

People were not always confident about raising concerns. Patients in the waiting area said they did not feel listened to about their long waits and enquiries about what would happen next. However, they told us they understood the department was under pressure and they thought staff were doing their best in difficult circumstances. Patients told us a member of staff had advised them to make formal complaints to the trust about their long waits for treatment as staff had raised this issue lots of times, but no changes had been made.

In line with trust processes staff sign posted patients to the Patients Advisory Liaison Service (PALS) to highlight their concerns.

Feedback from staff and leaders

Leaders worked to embed a culture of openness and collaboration, but it was not consistent. Some staff told us they did not report all incidents that regularly occurred in the department. For example, they did not always report high levels of demand impacting on staff ability to carry out all their tasks, and high numbers of patients waiting to be seen. Staff said when they had raised concerns about the large number of patients in the waiting area, especially overnight, their concerns had not been acted on. By operating continuously in these environments, there was a risk it would become normal to accept care that is below standard.

Staff said when they did report incidents, like patient falls, or pressure ulcers, the system was easy to use, and they saw reporting these incidents as an opportunity to learn and improve.

Processes

Learning was shared at staff safety huddles (risk meetings). Staff attend huddles at the start of their shift. If staff were late on shift, they checked in with the nurse in charge or consultant in charge who highlighted any key safety messages.

We saw evidence of learning from patient safety incidents. This included updating the standard for recording observations. This was to ensure there was limited variation in observation recording.

We asked the trust to provide us with incident data broken down by areas within the departments, including the level of harm associated with the incident. We specifically requested data regarding the waiting rooms due to concerns we had received prior to the inspection and because we observed significant waiting times during the onsite inspection. The data was provided by the trust, however it was not possible to identify the waiting room as a specific location.

We had access to information about 2 serious incidents that occurred in the waiting room. These incidents are subject to further investigation by CQC to see if regulatory action should be taken. As a result, this inspection will not report on the circumstances of those incidents.

We saw evidence to show when patients or their family made complaints these were taken seriously, and reports of the event were shared with them. People or those who represented them were given an apology and an explanation of the event.

People’s experience

Patients did not always feel there were safe systems and pathways to enable them to be seen promptly. Once people arrived at an urgent and emergency care service, it was important for their safety and health outcomes that they were seen promptly. Delays in getting care in urgent and emergency care services have been linked with increased mortality and illness.

We spoke to patients who had waited for up to 18 hours in the waiting room. This included a patient who had been brought in by ambulance who had been taken into majors for diagnostic tests and returned to the waiting area while decisions were taken about their care. Another patient with a suspected heart attack told us they had not received an electrocardiogram (ECG) to help diagnose heart problems until more than 2 hours after they arrived at the ED. According to the Royal College of Emergency Medicine (RCEM) an electrocardiogram (ECG) is an important test in suspected heart attacks and should be done within 10 minutes of arriving at hospital.

Some people had been required to remain in the waiting area for many hours. They were not able to sleep although refreshments were available for people to purchase from the vending machines. There were insufficient numbers of chairs for everyone, and some patients were having to stand. Patients told us how they were able to stop a frail older person from falling from their chair when they had fallen asleep in the early hours of the morning. There were agitated patients, some who were pacing the department.

However, patients in majors reported a more positive picture of receiving tests in a timely manner even when they had experienced a long wait on an ambulance before being brought into the department.

Feedback from staff and leaders

Staff told us patients were streamed (diverted) to the part of the hospital most appropriate for them by the streaming nurses who completed the initial assessment of patients arriving at the department either on foot or by ambulance. There were several treatment areas patients could be streamed to, including the urgent treatment centre, minor injuries unit, or one of the same day emergency care units. This helped reduce demand on the departments. This meant the patients waiting in the department’s waiting room likely needed urgent and emergency treatment for a serious or life-threatening condition.

After being streamed, patients were triaged. Triage is the assessment that takes place to prioritise patients for treatment based on the severity of their injury or illness. National clinical guidance for safety states patients should be triaged within 15 minutes of arriving at hospital. Due to exceptional demand and capacity pressures caused by a lack of onward hospitals beds, evidence showed during our inspection, waits for triage of up to 74 minutes for adults and 55 minutes for children and young people.

Staff knew about specialist teams who could support patients and how to contact them. For example, if a patient had a mental health problem, staff made a referral to a specialist mental health team which belonged to the local mental health provider. Staff told us there was not a support service for patients with autism and the service for patients with a learning disability, which also belonged to the local mental health provider, was not available out of hours.

Once in the adults or children’s department, patients sometimes had to wait for a long time until they could be transferred to a bed on a ward. Staff worked hard to identify patients that were well enough to be transferred and once a bed became available and they moved them quickly.

Staff told us they were sometimes worried about the safety of patients in the waiting room, particularly frail elderly patients who might be uncomfortable, or confused by their situation. They said the waiting room was often very busy overnight and could be overcrowded and noisy.

Feedback from partners

The hospital ambulance liaison officer (HALO), who was employed by the local NHS ambulance service, could also stream (divert) patients. For example, patients suitable for same-day emergency care could be diverted there by the ambulance crew rather than going through the ED first. This also meant, at busy times, not as many ambulances needed to queue to handover patients to the ED and they could respond to patients waiting in the community.

The HALO told us if patients waited for longer than an hour on an ambulance a doctor would go and assess the patient on the ambulance.

If patients arriving by ambulance required urgent treatment they would be transferred to the resuscitation area directly.

We witnessed the arrival of an air ambulance and saw the air ambulance and ED staff work together so the patient’s transfer from one service to another was safe and effective.

Processes

The adults and children’s departments used a process for all emergency attendances that meant patients were discussed with a consultant or other senior decision maker before they were discharged.

There was a clear pathway for staff to follow for when babies and very young children came into the children’s department to ensure they were reviewed by a senior registrar doctor.

There were processes for staff to follow if patients with learning disabilities or a mental health problem came into the department. This required staff to make a referral to a specialist team for support or specialist assessment. However, the new electronic patient record system which had flags that were used to identify patients with specific risks or needs, did not have a flag to notify staff if a patient had a learning disability, was autistic, or had dementia.

Senior staff monitored children who left the department before being treated. They contacted the family as soon as possible and informed support services if there were concerns regarding a child’s wellbeing. For example, the safeguarding team were contacted if there were ongoing concerns about the child’s welfare, or the police if there were urgent concerns about the child’s safety.

The trust had a clear process for transferring patients from one department to another. While the policy made it clear moving patients during the night was not desirable it recognised sometimes such moves needed to take place based on clinical need. This meant patients could be moved out of the ED and onto a ward overnight if a suitable bedspace became available on a ward.

Feedback from staff and leaders

There was an understanding of safeguarding across the service and staff knew how to take appropriate action. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to identify adults and children at risk of, or suffering, significant harm and worked with other agencies to protect them.

Staff knew how to make a safeguarding referral and who to inform if they had concerns.

Staff were aware of what to do if they felt patients lacked capacity to make decisions about their health care, this included following the Mental Capacity Act (2005) and making best interest decisions that included involvement from senior clinicians, the patient’s family, or a person authorised to do so.

Staff told us they did not apply for a Deprivation of Liberty Safeguard (DoLS) for people who lacked capacity and were trying to leave the department against medical advice. This was because these patients were usually in the department for less than 24 hours and DoLS did not apply. Staff applied the Mental Capacity Act (2005) to ensure these patients were supported by staff, often on a 1:1 basis, to remain safe in the department.

Processes

Not all staff had received safeguarding training to a level commensurate with their role and the trust’s policy. Only 58% of Advanced Nurse Practitioners (ANPs) had received safeguarding children to level 3. Healthcare assistants were only trained to level 1 in safeguarding adults (in accordance with trust policy) and not level 2 in accordance with national intercollegiate safeguarding guidance. Clinical fellows did not consistently complete level 3 safeguarding adults or level 3 safeguarding children.

A weekly audit was completed to assess the quality of safeguarding assessments performed by staff. The outcome of the audit showed staff consistently failed to ask all of the safeguarding questions as part of their safeguarding assessment. Between July and September 2024, staff in the ED asked between 11 and 80% of the set questions and in the same time period staff in the children’s department asked between 51 and 94% of the questions required to carry out a safeguarding assessment.

People’s experience

Individual risks to people were assessed, and people were involved in this process as much as possible. People understood the risks relating to them and what they could do to keep themselves safe. For example, how they could reduce their risk of falling.

However, people who were in the waiting room overnight told us clinical observations had only been performed once during the night. They said the waiting room had been very full and extra chairs had been brought in which made it difficult for staff to get to all of the patients, and staff had been busy doing other work. The trust sent us evidence to show the patients still in the waiting room at 8.05am on the second day of our inspection had their clinical observations recorded an average of 2.9 times overnight. Only 5 of 19 patients had 4 sets of clinical observations recorded. This was not in line with the trust policy which stated all patients, including patients in the waiting room should have their clinical observations recorded hourly for the first 4 hours in the department. Future observations should then be recorded based on clinical need.

We spoke to patients who had been assessed as well enough to wait in the ‘fit to sit’ area in majors. This area was a cubicle that had been repurposed to hold 8 chairs. The chairs were close together because of limited space but patients said they had regular observations by the nurse and health care assistant assigned to the area. The other patients in majors also told us staff regularly took their clinical observations.

Feedback from staff and leaders

Nursing staff knew which patients they were responsible for and when their observations were due. They also knew which patients required additional monitoring, for example, blood glucose or fluid water balance checks.

Staff attended daily and weekly safety huddles. These were meetings where important patient information was shared with staff.

Feedback from partners

The hospital ambulance liaison officer told us they thought the emergency department staff worked collaboratively with them to make good decisions to manage risk based on patients’ acuity. This included making decisions about which part of urgent and emergency care ambulance patients should be streamed to.

Processes

Processes did not consistently ensure individual risks were adequately assessed.

Staff received training in sepsis as part of their induction to the department. Compliance with this training was 100% for the adult’s department and 77% for children’s department, so there was more to do with those staff.

Not all patients received screening for sepsis within an hour or antibiotics on time. An audit was completed for patients with suspected sepsis to see if they had been screened, appropriately escalated, and given antibiotics within 1 hour, in accordance with national guidance. In June and July 2024, the paediatric team scored 100%. However, in August 2024, the paediatric audit showed 1 out of 4 patients with suspected sepsis was not screened and so did not receive antibiotics, which reduced the result to 75%. In the adult department, 50 patient records were used in the monthly sepsis audit. In June, the department scored 94%; July was 92% and August 90%. This was because patients who had a suspected sepsis infection were not consistently screened in line with guidance. This equated to 3 patients in June, 4 patients in July, and 7 patients in August.

There was guidance for staff to follow to ensure they conducted regular observations of patients in the department to monitor signs of deterioration. The guidance was for these to be completed a minimum of once hourly for the first 4 hours in the department, including for patients in the waiting room.

Each adult patient was required to have a National Early Warning Score (NEWS2) completed after being in the department for 4 hours. Each child or young person was required to have a Paediatric Early Warning Score (PEWS) or the Paediatric Observation Priority Score (POPS) completed after 4 hours. NEWS2, PEWS and POPS were used to measure certain clinical indicators for patients. They let staff know if an urgent response was needed if a sepsis marker was identified, and when they needed to escalate patients to a more senior clinician. We looked at 8 patient files and saw NEWS2 and PEWS scores had been accurately calculated.

We requested the audit results for the early warning scores. This was so we could see if these were being completed in line with the department’s guidance. We were told the ED did not audit NEWS2 or PEWS. However, following a ‘point of prevalence audit’ completed through the electronic patient record system in September 2024 the trust provided evidence to show that on average each patient had a NEWS2 score completed every five hours. The absence of a regular audit meant senior leaders were not assured staff were accurately completing NEWS2 or reassessing patients within agreed timeframes.

People’s experience

Due to the demand for hospital beds to move patients onwards and resulting capacity issues, patients were not always cared for in environments that were designed to meet their needs. Patients in the waiting room told us the waiting area was not large enough to comfortably hold the number of patients and their family members waiting to be seen. They told us overnight additional chairs had been brought into the room which meant there was no room for wheelchair users trying to access the room. Some people had to stand, sit on the floor, or wait outside because there was not enough chairs for everyone to sit down.

Patients in majors reported they thought the environment was good, although some patients who had been waiting on trolleys for several hours said they were uncomfortable.

Feedback from staff and leaders

Staff told us they did not always have enough equipment to care for patients and sometimes had to spend time looking for things. This included at times temperature probes, nasal cannulas for respiratory function monitors, ECG leads, and blood pressure cuffs. Staff required these items to monitor patients and identify if a patient was deteriorating and required escalation.

We were told some of the trauma mattresses for patients with potential spinal injuries were broken.

At the time of our visit, the air tube system that took blood from the department to the pathology lab was not working. As part of the planned business continuity plan in this event, additional portering staff were collecting the samples and transporting them to the lab hourly unless there was an urgent request that needed to be taken immediately.

Some staff told us that they did not think the adults’ waiting room was a safe environment for some patients, especially frail elderly patients, to wait in. They said sometimes patients had to wait there for a long time. They also said they did not like working in the waiting room because there were often angry patients who were dissatisfied with the long waits to see someone who took their frustration out on staff.

Observation

The adults and children’s departments were bright, modern, and felt spacious and airy, with the exception of both waiting rooms which were small. The waiting room in the children’s department had improved oversight from staff since our last inspection in 2018. However, we saw a young person sitting to one side by a vending machine who was not visible to reception staff.

Due to the demand for hospital beds to move patients onwards and resulting capacity issues, the patient waiting areas were not big enough for the number of patients they often accommodated. We saw patients and their relatives having to stand in the adult emergency department waiting area, we saw people sitting on the floor and standing outside because there was nowhere for them to sit. We saw staff talking to patients in doorways because there was not anywhere more appropriate to hold these conversations.

The waiting rooms had toilets, water coolers and vending machines. There were TV screens on some of the walls which showed information about waiting times and other hospital information. There was a computer game console in the children’s waiting area. However, there were no age appropriate, interactive toys or other items that might have reduced boredom for families who may have had to wait for several hours to be seen.

There was a co-located diagnostic imaging area for X-ray and computed tomography scans, so patients did not need to be taken to a different part of the hospital for these to be completed.

The adult’s and children’s departments were located on the first floor of the hospital and could be reached using an external set of stairs from the ground floor carparks, there was no lift to the department making it difficult for people with pushchairs and mobility problems to access the service. There was access to the department at the top of the ramp by car, but there were no signs to inform people they could drop people off at the front entrance.

Processes

To reduce risk from overcrowding in the waiting rooms there was a waiting area occupancy tool used by staff to monitor the number of people in the waiting room. It had instructions to escalate to senior staff once 60% occupancy was reached so actions to mitigate risk could be enacted including a board review of patients with the nurse in charge and the lead consultant.

There was a process to ensure the resuscitation trolleys were checked regularly and out of date equipment was replaced.

People’s experience

Patients in the waiting room who had long overnight waits to be reviewed by a doctor thought there was not enough staff. They told us the staff in the waiting room were kind and caring but they were very busy throughout the night. They sometimes had a long wait from when they were triaged, had diagnostic tests, and until they saw a doctor.

Most patients in majors told us they felt there were enough staff with the right skills and experience to look after people safely. They said the staff were well trained and competent with the care and treatment they were providing.

Feedback from staff and leaders

Leaders told us they kept staffing numbers at a safe level with a suitable skill mix. They used agency and bank staff when necessary, ensuring they were familiar with systems and processes within the department. The number of staff working overnight matched the number of staff working during the day. This ensured the resuscitation area was coordinated by a consultant 24 hours a day, as required for a major trauma centre.

During our inspection, the planned number of staff in the department matched the number of staff on each shift, supplemented by bank and locum staff when necessary. Staff said there were enough staff to ensure they were always able to take their breaks and finish their shift on time.

The children’s department did not have a dedicated paediatric consultant overnight or every weekend. However, 24-hour consultant support was provided by the adult ED consultant with additional support from the medical and nursing team from the paediatric ward to mitigate this risk.

Most staff told us they thought there was usually enough staff in the department. Nurses said they were able to escalate patients to doctors when they needed to. However, some nurses told us they were very busy due to the demand on the service, and they sometimes felt they had to rush in order to complete tasks that required higher levels of concentration and a slower pace.

Fluctuations in demand on the service sometimes meant there were not enough doctors on shift relative to the number of patients waiting to be seen. This problem was compounded by the inability to predict the level of major trauma that came through the department on any given day. This meant at times the department could be under staffed. The demand verses capacity rota for medical staff showed that between January and March 2024 there was an average of 32 more patients than there was capacity to see in a 24-hour period. On some days this reached as many as 70 patients more than the department had capacity to see.

However, the trust showed us a new rota which had been designed around a full year’s capacity and demand. This helped introduce consistent shift patterns and was modelled and tested against historical demand to ensure adequate coverage. Staffing has since improved, enabling the department to roster above those minimum levels. This had helped reduce the daily average number of patients than there was capacity to see down from an average of 32 to 6. Although on some days this figure was as high as 58.

There was consistently a minimum of 2 children’s nurse working in the children’s department. Nurses trained to work with adults received additional training in paediatric-specific competencies. The children’s department was supported by staff from the children’s ward, for example, if there was a child requiring resuscitation.

The department was supported by 2 nurse consultants, 12 advanced clinical practitioners (ACPs), and 14 trainee ACPs. ACPs came from a range of backgrounds and included nurses and paramedics who had gained additional qualifications to support the delivery of emergency care. Their skills meant they could provide safe and effective immediate care for patients with a wide range of conditions including those that were life-threatening. ACPs had expertise in resuscitation, and the knowledge and skills required to identify who needed admission and who could be safely discharged.

Observation

The waiting area did not always have sufficient or planned levels of staff to keep people safe given the clinical need of patients in that area. With the ability of the service to stream patients who did not need emergency treatment in an emergency department to other nearby or co-located services, there were therefore very poorly patients required to wait in the waiting room at times. At peak times, there could be 100 or more people in the waiting room. The planned establishment for staff was for patients who were waiting to be overseen by a streaming nurse, a second nurse, and a healthcare assistant. However, we did not consistently see a second nurse in the waiting area.

We saw some patients in the adults waiting room had very long waits to be reviewed by a doctor. Some patients who had arrived in the evening or during the night were not reviewed by a doctor until the following morning when the day shift began.

Processes

Staff received and mostly kept up to date with their mandatory training. Mandatory training was comprehensive and met the needs of patients and staff. Compliance with training was mostly above the 90% target set by the trust. Training modules included key areas such as fire safety, manual handling, infection prevention and control, equality and diversity, and information governance. Training was delivered through a combination of face to face and online learning.

There was a team who oversaw intermediate and advanced life support training provision. Their role included advising staff and managers if annual refresher training was due. We saw evidence that compliance with advanced life support (ALS), and European paediatric ALS, training among medical staff was sometimes low. For example, compliance with ALS for resident doctors was between 24% and 44%. However, compliance for consultants was 76%, clinical fellows was 63% and for career grade doctors’ compliance was 100%.

Paediatric consultant cover was from 8am to 7pm. There was a process for middle grade and resident doctors to follow if they required support from a consultant from the paediatric ward outside these hours. Staff said this process worked well. A business case had been submitted to extend the consultant cover the children’s emergency department from 8am to 10pm.

New medical staff received a full induction which included a period of shadowing that lasted between 1 and 2 weeks. Approximately 90% of locum doctors worked substantively, or had previously worked substantively, in the department.

The service made sure staff were competent for their roles and appraised staff’s work performance. Healthcare assistants and nurses were supported to develop their competencies with support from the practice education team. Compliance with appraisal was 87% for the adult emergency department staff and 94% for the children’s department staff.

To help keep patients and staff safe there were 2 security guards based in the adult emergency department 24 hours a day, 365 days a year.

People’s experience

Patients told us they saw staff wearing PPE and washing their hands.

With the way in which the waiting area was laid out, patients were often close to one another. Some patients told us they were concerned about infection prevention and control if any of the patients nearby had infectious illnesses.

Feedback from staff and leaders

Senior leaders told us they were working with staff to reduce the amount of PPE they wore. This was because during the COVID-19 pandemic staff had become used to wearing PPE at all times. They were encouraging staff to identify the difference between when they were required to wear PPE and situations where this was no longer necessary.

Observation

Staff washed their hands in between working with different patients. They wore PPE appropriate to the tasks they carried out.

Staff followed a process of clear signage to ensure other staff, patients, and visitors to the department, did not enter the side rooms of infectious patients.

The environment was visibly clean, and we saw housekeeping staff working in the department throughout the day. We saw ‘I am clean’ stickers on equipment to show it had been cleaned and was ready for use.

The signage on clinical waste bins was magnetic, this meant the outside of the bins were easy to keep clean. Staff disposed of clinical waste safely. Clinical waste bins were emptied regularly.

Processes

There were processes for assessing and managing the risk of infection, which were in line with current relevant national guidance and standards. Staff received appropriate infection prevention and control (IPC) training and had clear roles and responsibilities. When IPC audits demonstrated lower than expected standards, actions plans were devised to improve compliance.

People’s experience

Most patients said they received the medicines they needed. However, a patient in the adults’ waiting room who had collapsed at home with chest pain said they had to ask several times about being given aspirin before they received it. This patient was under the belief they needed aspirin. They waited for 12 hours before being reviewed by a doctor and informed aspirin was not appropriate as the pain was non-cardiac chest pain.

Most patients told us their pain levels had been assessed and they had received pain relief.

Feedback from staff and leaders

There were no dedicated pharmacists or pharmacy services within the adults or children’s department. However, staff told us that they knew how to contact pharmacy for advice and there were processes to ensure an effective supply of medicines to the department.

Although staff knew how to contact pharmacy for advice and support, staff we spoke with said they saw a need for a pharmacy presence within the department. The Royal College of Emergency Medicine recommended the use of dedicated emergency department pharmacists and pharmacy services to work as part of the multidisciplinary team. This would help provide clinical and operational support for the safe and efficient delivery of care to patients in the emergency department.

A new electronic prescribing medicine administration system had been in operation since June 2024 which staff told us was functioning well.

Staff told us they had access to relevant and up to date medicine policies, procedures, and guidelines through the trust intranet.

Observation

We observed medicines were locked and secure and were stored safely in line with recommended practice.

Medicines storage was secure with access only to authorised staff. The use of automated electronic medicine storage units were used to support nursing staff to locate the correct medicine and was designed to support availability of medicines.

Resuscitation medicines required in an emergency were stored safely in tamper-evident trolleys which followed Resuscitation Council (UK) guidance. We observed staff record 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.

Time critical medicines such as medicines for Parkinson’s disease or for seizure control were stored safely and immediately available in the electronic units.

Processes

There were processes to ensure people received their medicines as prescribed. Medicine administration records were legible and correctly written.

Patients’ past medical history including any prescribed medicines were recorded on the electronic admission notes.

We reviewed 3 patient medicines administration records. They were well documented with route and time of administration, including a recording of the reason a medicine was not given. The information we looked at showed people were receiving their medicines as prescribed.

The new electronic system flagged any missed doses and remained flagged until the medicine was administered. We saw this demonstrated for an antibiotic that was due which had been automatically flagged as a reminder to staff to administer. Where a ‘PRN’ (when required) medicine was administered, staff recorded why it was needed. For example, a pain relief medicine was documented with the time of administration and the reason recorded.

Patients’ weights were recorded. However, they were not documented on the patients’ electronic medicine administration records which would have supported calculating weight-based medicines prescribing.

Allergy status of patients was routinely recorded on all medicine records seen. This meant allergies were highlighted, and medicines could be prescribed safely.

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

Controlled drugs (CDs) (medicines requiring more control due to their potential for abuse) were stored safely and securely with access restricted to authorised staff. Daily CD checks were undertaken and recorded by 2 members of staff. 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. There was a good safety culture around medicines that encouraged staff to report these incidents.