New Cross Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We rated safe as Inadequate. We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

At our last inspection we rated this key question good. At this inspection the rating has changed to inadequate. This meant the service was not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of the legal regulations relating to safe care and treatment and there were increased risks to patients due to the crowded environment.

We have not awarded this service a score for Safe.

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

The service did not have a proactive and positive culture of safety, based on openness and honesty. They did not always listen to concerns about safety. Although safety events were investigated and reported, lessons were not always learnt to continually identify and embed good practice.

Safety was not a top priority that involved everyone, including staff as well as people using the service. There were limited avenues for staff to learn from complaints, incidents, and audits. Staff were mostly emailed updates in the form of ‘making it better’ alerts and ‘risky business’, but not all staff had time to regularly check their emails or could recall changes or updates required. Staff told us updates also relied on ‘word of mouth’. However, the trust sent us information where audit results had been communicated and compliance had improved. The sepsis pathway audit results had improved from 24% in August 2025 to 100% in November 2025. Staff were supported to prioritise their time to receive the education required for the improvement.

Nursing handovers were documented daily and records showed they were not well utilised for key messages. We reviewed handover records prior to the inspection and found there were limited messages communicated and the notes lacked detail. However, during the inspection, we observed the medical and nursing handovers, and they delivered key messages and learning following our feedback the previous day.

Managers told us they were planning on implementing safety huddles throughout the shift, but this had not yet happened.

Whilst most staff could not, a few members of staff were able to recall changes following an incident. We were told about an incident where allergies were not checked for a patient and resulted in harm. The service had changed the medicine charts to include 2 sources of cross checks for allergies and updated the policy. The service audited the completion of the allergy box and training had been done with the teams. However, we were also told about examples where incidents had happened, and nothing was changed. For example, a member of staff was attacked in triage by a mental health patient, they could not reach the buzzer, and no one could hear them shouting. We were told there had been no feedback to staff and no changes implemented to improve staff safety.

Staff did not always get shared learning opportunities from the incidents unless they reported the incident themselves. Staff received feedback individually if they reported an incident. The trust’s formal reporting system was easy to use. We found there were no checks to ensure any learning was embedded and practices were changed.

People and staff were encouraged and supported to raise concerns but felt actions were not always taken as a result. Most felt confident that they would be treated with understanding, and would not be blamed, or treated negatively if they did so. Staff told us most managers were supportive if they raised concerns but were not always sure of the actions taken following raising the concerns.

Staff in paediatric emergency department (PED) told us they received feedback from incidents, and they were seen as learning opportunities. Learning was shared at handovers and staff gave us examples of this learning.

Following traumatic incidents, the teams in both ED and PED had ‘hot debriefs’ followed by a ‘cold debrief’ a few weeks later. We were told in PED they involved psychology and a nurse trained in paediatric deaths, and learning was taken to their study days.

There was a learning messages log which had a list of all learning circulated to staff in the last 12 months. Recent messages included complaint’s themes, allergy status and winter pressures and staff wellbeing.

Risks were sometimes overlooked and were not always dealt as an opportunity to put things right, learn and improve. For example, all staff told us the waiting room was a risk, and no efforts had been made to improve the safety of the waiting room and this was not on the risk register. We fed this back to the trust and from 3 December 2025 they redeployed a healthcare assistant into the waiting room 24 hours a day to monitor the waiting room and support with patient safety checks.

Incidents and complaints were investigated and reported. Managers met weekly to discuss complaints and incidents and they were also discussed in monthly ED governance meetings.

The service looked at patient safety incident investigations in line with the Patient Safety Incident Response Framework (PSIRF). We reviewed 2 after action review reports and found them to lack detail and action. One report had no actions despite there being learning found in the report, the other showed learning points but it was not clear how they were actioned or when these actions had been completed.

We saw evidence that the duty of candour was completed in the ED. We looked at ED directorate governance meeting minutes and saw duty of candour completion was discussed for each incident. We also saw 5 completed duty of candour letters for other incidents.

Staff reviewed incidents involving patients with mental health needs. We saw they were detailed in the safeguarding group report. Following an incident, members of the psychiatric liaison team, the lead matron for mental health in the ED and the trust group mental health lead held joint incident review meetings. Recent incidents included patients absconding and registering a patient under the wrong name.

There were paediatric mortality meetings and mortality reviews were discussed in consultant meetings. This was also an agenda item at governance monthly. We reviewed 2 meeting minutes and neither had discussions regarding mortality within the meeting. There was a learning from deaths governance process where cases which met a criteria or where concerns were identified were escalated for a structured judgement review. These reviews were bed back to the directorates for discussion.

We found the trust leadership team were responsive to the feedback we gave them and acted promptly to improve the care and learn lessons. They provided assurances to the issues we raised and put immediate actions into place to improve the care for patients.

The systems and pathways did not support safe systems of care. Staff were not able to make sure there was continuity of care, including when patients were in SDEC and discharged from this area.

There were systems in place to protect staff, but these did not work. There were security on site who attended the emergency department when staff needed assistance. However, staff told us they often took a long time to come. Staff in the SDEC told us they felt vulnerable, especially at night. They often had patients who were verbally aggressive towards them due to the long waiting times and had implemented a temporary trial process called ‘overnight procedure for SDEC’ where SDEC patients were admitted in cohorts of 10 patients from ED. This had not tackled the long waits which was the main cause of the aggression. When the SDEC waiting room was full overnight, all other patients waited in the main waiting room which became overcrowded. At 6am all patients were allowed to come into the SDEC waiting room again and at this time, there were often waits of over 12 hours to see the doctors.

The streaming process in ED was not always adhered to, and people were treated in inappropriate areas. There was an ED streaming and front triage process to ensure patients were streamed and triaged to the right areas for their needs. During our inspection we found multiple examples of patients who were inappropriately transferred to SDEC. SDEC was open 24 hours a day 7 days a week with an exclusion criteria. Staff told us this was not adhered to most of the time. Staff in ED told us they used SDEC to complete care when they needed space in majors. This meant patients could be transferred back down to the major’s department as they had not been appropriately assessed and their condition was not in line with the SDEC criteria; we saw a few examples of this during our inspection.

The service had several pathways including an SDEC pathway, chest pain, diabetic ketoacidosis, and community acquired pneumonia pathway. We found the service did not always adhere to all the pathways in place.

Patients were being streamed to SDEC but there was not always physical space for them to move. We found some patients were being held in the main waiting room downstairs, but they were moved on the computer system into the SDEC numbers. There was a risk staff would not know where the patients were and little clinical oversight.

The streaming nurse in the waiting room was not always present. The service had a streaming nurse in the waiting room to assess patients and stream them to the appropriate area. They often took patients to the area they needed to be in, and this meant at times, there was no streaming nurse. There were also not enough streaming nurses to always ensure cover. Following our inspection, the service had redeployed a non-clinical “flow runner” to be assigned to assist in navigating patients to the relevant clinical areas. This ensured the streaming nurse could remain in the waiting area during peak levels of activity.

There were not always emergency nurse practitioners (ENP) on until 10am, or 12pm. Injury patients were seen in a see and treat area. Doctors were allocated to cover when ENP’s were not on shift. All injuries patients were seen in SDEC overnight in time order with all other patients. We were told at times this meant people with injuries were sent to SDEC, waited all night due to long waits in the department, and then were sent down to see and treat the next morning. This meant a poor experience for the patients who waited for hours and a poor experience for the ENP who started their shift with a backlog of patients to see. We fed this back to the trust and on 26th November 2025 we saw a doctor was allocated to see these patients prior to the ENP attending to ensure there was not a backlog when they arrived on shift.

The service did not ensure the hourly safety rounding checklists for patients were completed. The checklist included pain assessments, pressure area care and falls risk assessments. The trust audited documentation monthly and results for September 2025, showed average time between checks was 2 hours 24 minutes, on average people stayed in the department 11 hours 54 minutes and they had 5 hourly checks done. We saw no action plans to improve compliance. We reviewed the records of 12 patients and found that none of these patients had care plans completed hourly. We fed this back to the trust who told us since our inspection they had revised the hourly checklist, and an updated version was in use. The frequency of the rounding had changed and was now based on risk according to the patient need and was a minimum of 2 hourly.

The department had a pathway for patients with mental health needs, but this was not always followed. Patients did not always have enhanced observations when required. Triage nurses completed an initial assessment and identified patients with mental health needs. They also completed the departmental mental health risk assessment tool. The trust recognised that this was not a full tool as suggested by Royal College of Emergency Medicine (RCEM). Training had been planned in the full tool, but it had not yet been delivered fully.

The members of staff we spoke with were not clear on the process for ensuring that mental health patients assessed as being at high risk were observed following triage. The mental health risk assessment tool suggested that 1:1 continuous observation should be implemented for patients identified at high risk. Following triage, the department tried to allocate patients with mental health needs to cubicles. However, members of staff we spoke with told us patients sometimes waited in the sub-wait area or were sent to SDEC. These areas did not always have a member of staff in them and 1:1 care was not always provided.

Where a Mental Health Act assessment was needed, there were processes in place for this to be requested and appropriate staff would attend the department to carry these out and record their assessment and decision. All members of staff we spoke with could describe the pathway for mental health patients, including risk assessment and management.

There was a psychiatric liaison service providing nursing cover 24 hours a day, 7 days a week. The team planned to have 2 nurses on each shift, but this could be increased if they had a heavier caseload.

Some pathways worked. We saw policies and processes about safety were aligned with other key partners who were involved in people’s care journey to enable shared learning. There were referral pathways into the ED, and they worked with the ambulance teams to ensure the correct patients were conveyed to their department. There was a stroke pathway that worked well. There was a direct line from the ambulance to the stroke nurse. The stroke team were very responsive with 24 hours cover. Where there were delays due to flow, patients with a suspected stroke still had a scan of their head promptly in line with their pathway.

The service had information systems that allowed them to see patients GP records to ensure continuity of care. They worked alongside several services such as ambulances, psychiatric liaison team, older persons assessment and liaison team, alcohol liaison team, and clinical specialities. Referrals were made to enhance patients’ care and patients were reviewed and assessed by services effectively.

There were electronic alerts used to make staff aware of a patient vulnerability.

There were 2 handovers a day at the change of each shift. These contained key safety information about the patients who were in the department at the time. The nurse in charge (NIC) and the consultant in charge (EPIC) had good communications throughout their shifts to highlight any potential safety concerns. However, please see learning culture for details on wider information sharing and learning within the handover. Handover information was stored in a paper file.

There was a flow co-ordinator on Monday to Wednesday who assisted the nursing team with flow in the department. They also had flow runners who moved patients in the department, this meant the nurses could continue with other vital tasks.

There was a discharge facilitator who assisted with admission avoidance and liaised with social workers and therapy teams to try and get patients home safely.

There were rapid response occupational therapists and physiotherapists who attended the ED daily. They enabled people to be discharged home with equipment to support them rather than being admitted where appropriate. They made referrals to social services, intermediate care teams in the community and rehabilitation hospitals when required. They supported safe discharges into the community setting.

Information was shared between different teams when patients were discharged. Discharge summaries were automatically sent to patients GPs, and a copy was given to the patient if they were sent to a care home. Verbal handover was also given where possible.

The service worked with people to understand what being safe meant to them and the best way to achieve that. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Data showed 95% of staff were trained to level 3 safeguarding adults and 93.3% for safeguarding children; this was a significant improvement from our previous inspection where safeguarding training levels were low.

There were effective systems, processes and practices to make sure people were protected from abuse and neglect. There was a clear safeguarding policy and pathway which was accessible to staff. All staff we spoke with knew how to make a safeguarding referral and who to inform if they had concerns. Staff had access to the trust’s safeguarding lead for advice. The trust adult safeguarding team attended the department daily.

People were supported when they felt unsafe or experienced abuse or neglect. Staff told us how they would support these people, including children. There was a dedicated safeguarding lead for children and there were daily, open discussions with the safeguarding team. They attended the department on Monday, Wednesday and Fridays. They assisted staff with ensuring checks were completed for children.

Staff followed a process when adults, who were parents of unwell children, left the ED without completing their treatment. They would phone the parent and if they had a safeguarding concern, the police would be informed. If their clinical observations were out of normal range, an ambulance may be called to their house. They also completed an audit for patients who did not wait and ensured they were managed in line with policy.

Staff identified if children were at risk of exploitation. There was a log in the department and referrals were made to a charity who would support these vulnerable children. There were a number of organisations the department could refer children to, to support them whether it was with medicine use, knife crime or mental health needs.

Staff in the department received training in the Mental Capacity Act and Deprivation of Liberty Safeguards. Senior managers felt this supported them to make decisions when people were in the department for an extended time.

Staff completed a ‘Mental Capacity Assessment for adults and young people’ form when considering a person’s capacity. This included sections for what the specific decision the assessment was in relation to and the person’s ability to understand, retain, weigh up and communicate their decision. There was mental health representation at the trust’s Safeguarding group.

There was an emergency services safeguarding meeting with an action plan summary report. We saw actions were discussed monthly and regular updates were recorded.

The service did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe due to departmental pressures. Crowding in the department caused by the demand for hospital beds, meant the service was not able to manage patients risks safely at all times. Some observations of risk were not identified or acted upon quickly.

There was a lack of clinical oversight in the waiting room and no clinical checks of these patients who were often waiting for hours. There was a risk that a deteriorating patient within the waiting room would not be identified. The service had assigned a streaming nurse to the waiting room to assess patients and stream them to the appropriate area. They worked from 10am until 10pm Monday to Friday, although were not always available in the week. For example, there was no streaming nurse on 26 November 2025. This meant there was no clinical oversight in the waiting room. Triage nurses came into the area to call their patients but there was no continued clinical oversight of the waiting room.

There was a risk that unwell patients were not detected whilst they waited for triage. Observations were not routinely completed on patients in the waiting room despite them waiting for hours to be seen for triage. During the inspection, we observed the streaming nurse and saw observations were not routinely performed on patients. There was no cover for the streaming nurse if they were on their break or were away with a patient and there were no streaming nurses overnight or at weekends. This meant all patients who attended the ED at these times were not streamed and booked straight in at the reception desk. Reception staff added “PP” to their record if they needed to be seen as a priority based on a list of pre-agreed conditions. We saw a number of examples where patients waited a long time in the waiting room, including patients with suspected heart attacks and were put at risk of harm. All staff we asked about the waiting room felt it was unsafe, and they were unable to detect a deteriorating patient. They felt it was high risk.

Patients were seen in order of clinical priority. We looked at 17 sets of records and found all patients had a completed triage; this included 5 sets of children’s records.

Ambulatory patients in the ED were not always assessed in a timely manner. Waiting times for patients to be triaged were significantly above 15 minutes. This was the recommended standard time for patients to have a completed triage by the Royal College of Emergency Medicine (RCEM). For example, during the inspection there was a 2 hour 7 wait to be triaged. We also saw a 78-year-old patient who arrived with abdominal pain was not triaged for 4 hours.

We fed the waiting room concerns back to the trust and they redeployed a healthcare assistant (HCA) into the waiting room to assist with observations of the patients. The presence of the HCA provided prioritisation of patients in the waiting room, in line with any changing condition or deterioration. During the inspection we saw that due to a staff member being assigned to the waiting room, an unwell patient was picked up immediately and seen promptly. The service also re-established observation taking into the streaming nurse role, aligned with RCEM prioritisation standards. This meant initial observations were taken on arrival to the department and unwell patients were prioritised for a prompt triage.

We observed 7 patients being triaged during the inspection. We found risks were not always assessed, past medical history was not always ascertained, and pain score was not always completed. For example, a patient came in with a head injury, and they were not asked about loss of consciousness, vomiting or headaches or blurred vision. The triage was lengthy which meant patients were being seen slowly. Following the inspection, the model in triage was amended to ensure the only treatment in triage would be analgesia or medicine that reduced a fever to ensure a quicker triage process. All other interventions would be picked up in the next stage of the process. An additional band 7 had been deployed to support triage in early November 2025. The service had seen a reduction in triage times, but this had not been sustained.

Patients arriving by ambulance were triaged in the ambulance receiving centre (ARC) but there were often delays. To mitigate risks, patients who arrived by ambulances presented to ARC for a prompt triage, including observations, with the nurse who had a visual look at the patient. This was documented in a triage booklet and on their computer system. Patients were then transferred to a cubicle or put back on the ambulance if one was not available. A rapid assessment triage (RAT) was completed in time order, unless there were clinical concerns from the triage, by an experienced clinician. During the inspection there was 1 hour 36-minute wait for a trolley in ARC, but all patients had received a rapid triage. Trolley wait times varied and delays were not always significant. Although, paramedics told us they often queued out of the ARC area down to the external doors whilst waiting for triage.

Triage times within PED were mostly in line with Royal College of Emergency Medicine (RCEM) but could face lengthy waits to be treated due lack of flow and short staffing levels.

Pathways created to keep the patients safe were not always adhered to. For example, we found the chest pain pathway was not always followed and there was a lack of oversight from managers that this was not happening. We looked at 5 sets of records for patients who had attended with chest pain within the previous 24 hours of our inspection. We found only 1 out of the 5 patients had received an electocardiogram (ECG – heart tracing) within 15 minutes in line with their pathway. One patient waited nearly 2 hours for an ECG. During the inspection there was an hour wait for an ECG. This meant any patient attending ED with chest pain would not get an ECG within the 15 minutes time frame. Following the inspection, the trust implemented a daily audit of the effectiveness of the chest pain pathway. The HCA who had been redeployed to the waiting room was also able to assist with extra tasks such as ECGs where required.

We saw there were inappropriate patients on the SDEC unit. Staff told us patients who were sent to SDEC did not always fit their criteria; however, there was no data to confirm this at the time of the inspection. However, we saw multiple examples of patients who were inappropriately transferred to SDEC and did not fit the criteria, and some patients were moved back to the ED once they had been seen. For example, we saw a patient was sent to SDEC with active chest pain, they were then fast tracked to cardiology after waiting 5 hours in SDEC; staff in SDEC told us this was a regular occurrence.

SDEC was not used as an SDEC and was used as an extra medical area to accommodate the volume of patients in the ED. More was needed to be done to ensure patients were seen promptly overnight. Overnight SDEC became very overcrowded due to long waits and patients became aggressive to staff. During the inspection there was a 12 hour wait to be seen by a doctor in SDEC. This contributed to a poor patient experience, and increased frustration from staff and patients. We fed this back to the trust, and they immediately put actions into place to improve the use of SDEC including changing the layout and zoning it into different ED and medical SDEC areas.

The lack of prompt radiology result sign off resulted in the potential risk that patient results were not acted upon. There were 16 hours a week where an ED consultant was assigned to sign off patient ED images that had been reported. In addition, other clinicians working in SDEC and ARC had 1 hour prior to a substantive shift to review results; this was an additional 4 hours per day. However, we saw an example of delays in reporting and lack of action during our inspection. A patient came into ED with abdominal pain and had an X-ray which was not reported on, and the patient was sent home. They returned on 4 days later with increased pain and the Xray had been reported as a small bowel obstruction. This had not been escalated by the radiologist who reported it, and no one had followed the patient up. The only reason they were seen was the patient had re-presented to the department in further discomfort. We were not assured that all patients results were acted upon. The service provided evidence about their process, but they stated they would strengthen the oversight to deliver more reliable assurance. A register for all discrepancies and recalls would be implemented and a recall audit undertaken weekly to ensure these were reviewed.

Staff did not always act to reduce the risks for patients. We were not assured hourly checks such as patient comfort, pressure area care and tissue viability were completed. There was an hourly safety checklist to complete on patients who had been admitted to the department, but we saw this was not completed hourly for any patients in all 12 of the notes we reviewed. This checklist included ensuring patients were turned if they were high risk of pressure damage, ensuring they had a drink and asking if they were in pain.

Once they were in the department for over 6 hours they were moved to a long stay pathway. However, we found in the notes we reviewed, patients were not always moved onto the long stay pathway after 6 hours. For example, we saw a patient was admitted and not started on the long stay pathway for 16 hours. Following the inspection, ED managers reviewed the safety checklist and updated it, and the frequency of checks was based on risk and patient need and was a minimum of 2 hourly.

We saw that as delays within the department increased, patients were waiting for long times to be moved from ambulance offload bays or from the waiting areas into the department. We saw safety checks did not always take place to ensure deterioration was recognised and acted upon. The long stay pathway was not always completed correctly and lacked detail. Staff told us they were time pressured and did not have time to complete paperwork properly.

The department were better than regional average in the percentage of ambulance handovers being completed within 30 minutes. In September 2025, 74.5% of handovers were completed within 30 minutes, with 7.7% taking 30 to 60 minutes and 17.8% taking over an hour. This was above the Midlands regional average of 65.6% of handovers completed within 30 minutes.

There was a lack of flow within the hospital. During the inspection, we saw at 7am there were 24 patients who had been reviewed and were waiting a bed within the hospital. There were 146 patients in the department, and an 11 hour wait to be seen by the doctors. There were 5 patients who were on ambulances waiting to be seen on ARC. The trust applied a push model where patients were “pushed” up to the ward into an extra bed space. These patients had all been seen and accepted by medical or speciality doctors and were awaiting beds on the wards. During busy times, this happened three times a day to free up space in the department. This happened on both days of our inspection. There was a criteria for patients who were able to do this.

Risk assessments were not always completed for patients. For example, we saw venous thromboembolism (VTE) assessments were not completed. Medical staff told us this was the responsibility of the wards when the patients were transferred. We saw a patient with a history of a stroke, on aspirin and prescribed enoxaparin without a VTE assessment. We discussed this with a consultant who said the staff just make a clinical judgement and the risk assessments were not used.

Staff used nationally recognised tools to identify deteriorating patients. These were recorded electronically, and scores were automatically totalled. We saw where National Early Warning Score (NEWS2) and Paediatric Early Warning Scores (PEWS) were high, these were acted on appropriately and reassessed in line with guidance. NEWS2 and PEWS scores were displayed on the department overview screens. This meant the nurse and consultant in charge could see a patient who had a high NEWS2 score and ensure action was being taken. Records we reviewed showed deteriorating patients were acted upon promptly. There was an immediate care clinician who was a senior doctor who carried a phone. This meant they were easily contactable if a patient deteriorates and they needed prompt assistance. Staff told us this worked well.

PEWS scores were entered electronically, and the system recognised the child’s age and put the observations onto the appropriate chart. Any out-of-range PEWS scores were flagged to clinicians.

The NEWS2 determined the degree of illness and was based on the patient’s vital signs. The score helped to identify patients most at risk of deterioration or sepsis. There was a specific form to assess sepsis which had recently been updated in line with updated National Institute for Clinical Excellence (NICE) guidance. The pharmacist told us they checked medicine charts to ensure patients had their antibiotics in line with guidance.

There was good oversight of patients by the senior team in the department, apart from in the waiting room. Each computer in the department had access to the patient management system which displayed an overview of the patients. It showed the length of time each patient had been in the department, or on an ambulance, or were waiting for triage, or treatment. Resident doctors told us they discussed every patient with the consultant in charge. However, managers did not always anticipate where the greatest risks were or ensure these areas were staffed appropriately. We saw staff did not have time to complete tasks and patients waited a long time for triage and treatment.

There was a front triage clinician, in addition to the triage nurses,. There was a cohort of patients that may need an urgent medical review following the nurse triage assessment. These patients were reviewed by the front triage clinician. If this role was not filled all patients that required an urgent review were discussed and escalated to the Consultant in Charge. Nurses told us this worked well and helped with triage times. However, we were told this role was usually covered 5 out of 7 days due to staffing constraints.

Where patients had been identified as requiring 1-to-1 therapeutic observations, the shift co-ordinator booked a member of staff from an external agency. The members of staff we spoke with told us that they were responsive. Whilst waiting for this member of staff to arrive, co-ordinators asked 1 of the HCAs to complete these observations.

One of the 2 patients who were in ED for mental health concerns whose records we reviewed had been identified as requiring 1-to-1 observation. An HCA had recorded in the notes that they had completed these observations., but they did not document the observations. The trust had a Policy for Care of Patients Requiring Enhanced Care. It included a risk matrix tool to guide staff on when to request 1-to-1 supervision.

The records we reviewed showed all patients received an assessment of their physical and mental health needs, where necessary, on their arrival at the emergency department. This included details about any risks to themselves or others.

One member of security staff was in the department during the day and 2 at night. Security members of staff did not complete therapeutic observations, but they would support restrain patients. Security members of staff had received a 2-day training course in restraint. Security members of staff completed body maps following any restraint, this was audited.

There were alternative areas and processes for sending patients who did not need urgent and emergency care. There was an urgent treatment centre (UTC) which was staffed by advanced nurse practitioners, nurse practitioners and GPs. Patients could be sent here by the streaming nurse if deemed appropriate.

The leaders assessed the department regularly throughout the day using the NHS England Operational Pressures Escalation Levels (OPEL) framework. It generated different responses depending on the overall score. It had 4 different levels with level 4 being the highest pressure which meant they were unable to deliver comprehensive care. On 26 November 2025 at 7.15am, the department was OPEL 4.

The service did not control potential risks in the care environment due to crowding in the department. Staff did not always make sure equipment, facilities and technology supported the delivery of safe care.

We saw the environment was visibly clean, but it was crowded, and patients were staying in the department for long periods of time. People were not cared for in a safe environment that was designed to meet their needs. The emergency department was spread out and there were different areas for patients to be seen in. There was an ambulance receiving centre (ARC) with 11 trollies, 2 further ambulance offload areas including 7 curtained trolley beds, majors with 31 trolleys, 5 resus spaces, 3 see and treat rooms, an SDEC and Urgent Treatment Centre on the first floor, accessed by the lift.

Not all facilities and premises were appropriate for the service being delivered. There were not enough cubicles in majors to care for the number of patients in the department. This meant patients were cared for in areas which were not designed for longer staying patients. Patients spent long periods of times, often more than 12 hours, in chairs and on trolleys. Despite best efforts to ensure patients had hospital beds who needed them, there were not enough hospital beds, and too many patients were high risk and staying over 6 hours. We saw patients remained on trolleys longer than 24 hours.

SDEC had 6 trolley spaces, 5 assessment rooms, 2 side rooms and a 5-bedded bay. There was an exclusion criteria to ensure only appropriate patients were in this area as it was not considered safe for high-risk patients, but this was not adhered to. The department remained crowded in all areas and patients remained overnight in chairs and trolleys.

Following the inspection, the service zoned the SDEC to assign specific areas for patients on ED and medical SDEC pathways. The change aimed to deliver improved clinical oversight and improved patient experience.

There was limited space and privacy in some of the areas such as the ambulance offload areas. The spaces only had curtains between them which could not be drawn together and there were 4 chair spaces which were very close together and provided no privacy.

Paediatric ED (PED) had 6 cubicles, 1 of them which was ligature light and 2 which were high care spaces and 2 sensory rooms. One of the sensory rooms had floor mats, and wall protection mats and bean bags. When a patient was deemed as high risk all ligature risks were removed from the cubicles making them as ligature light as possible. There was a checklist for nursing staff to complete to ensure this was actioned. These high-risk patients were nursed in the highest visibility cubicles. There was a separate paediatric waiting room and their own triage.

We saw patients who stayed overnight in the ambulance offload area in chairs, and people waited in the waiting rooms in both the main ED, UTC and SDEC all night.

The waiting rooms were large but due to the lack of flow through the department, became overcrowded and this increased the risks for some patients. For example, there was no area to safely isolate chemotherapy or neutropenic patients from the waiting room where there were potential covid or flu patients.

There were safety concerns for staff within the see and treat rooms. They were isolated within the department. The emergency nurse practitioners told us they felt vulnerable at times due to their room location and lay out. Rooms had emergency buzzers and panic alarms but staff told us the emergency buzzers were not set up to highlight their room appropriately.

The department had a room for assessing mental health patients. This room met Psychiatric Liaison Accreditation Network standards.

Nursing staff told us they would try and place mental health patients in cubicles nearer to the nurses’ station if the mental health room was in use. Staff completed a review of risks in these cubicles and, where possible, removed items that could be used to self-harm. Staff were aware that the cubicles contained potential ligature risks. We saw resuscitation trolleys contained ligature cutters.

There was not always enough equipment to keep people safe. For example, there were not enough cardiac monitors for patients to all be monitored when they needed it. One patient told us that although she had been told she needed to be on a heart monitor there were not enough monitors for her to be monitored. She also told us staff said, “even if we had a monitor there is no one to monitor it”. Equipment was sourced from the clinical equipment resource library. But staff told us they did not always have the appropriate equipment to administer treatment.

Resuscitation trolley checks in majors and ARC were not consistently completed. We found gaps in the records for this in November, October and August 2025. There was a weekly check alongside the daily check which was mostly not completed. The resus trolleys had a sticker seal with a serial number on it which was recorded on the checklists. Both the trolley in majors and ARC’s seals looked tampered with and were easily removed. There was a risk that items could be removed from the trolley and not be available in an emergency.

The trust completed an annual audit of the adult and paediatric resuscitation trolleys between August 2024 and July 2025. Ed Majors and ARC were 100% compliant with the audit. Some gaps were found for SDEC and Plaster room. An action plan was created but was not shown as completed.

There was space for relatives to have some peace and quiet. There was 1 relative room in adults and 1 in paediatrics and 2 SWAN relative rooms. This was in use for families and ensured they had a quiet space to grieve or have private conversations with medical staff.

The facilities were well maintained, and any equipment used with patients was in good working order and used safely. Staff wore personal protective equipment in line with regulations.

Hazardous and clinical waste was responsibly managed.

The service did not make sure there were enough staff to meet patients’ needs due to the crowding and capacity of the department. Due to the crowding and lack of available beds in the rest of the hospital, there were more patients in the department and waiting on ambulances than the staffing establishment was designed to safely manage. Numbers of staff on shift were in line with safe staffing during our inspection. However, staff told us this was not always the case. There had been a recent workforce review to increase the number of nurses within the ED to 24 registered nurses in the weekdays and 21 at weekends, but we were told they rarely had 24 nurses on shift.

The nurse in charge completed the ‘Safe Care’ module within the electronic roster at each shift which informed the daily divisional safe staffing huddle. This rated the staffing as red, amber or green. This could be moderated by the nurse in charge if there were mitigations which changed the level. Senior leaders told us they could safely staff the areas with 20 registered nurses which was not in line with the workforce plan. We saw there were days when the department was ‘Red’ on Safe Care and no action taken to improve the staffing. For example, before the inspection there were days where there were 18 registered nurses on shift. One staff told us staffing was a “huge concern”.

Staff in both the ED and SDEC did not have time to deliver safe care to their patients. For example, all sets of notes we looked at showed the hourly checklists were not completed, ECGs were not completed on time and there were long waits for triage.

We raised this with the leadership team, and they told us they used the Emergency Department Safer Nursing Care Tool 2021 to determine their numbers and did a biannual skill mix review; these were approved annually by the Trust board. ED staff were rostered using an electronic roster system which identified key skills required. Rosters were devised from agreed establishment based on skill mix requirement for each shift. There was an operational lead allocated daily to attend cross Trust bed meetings, to communicate and escalate any concerns regarding patient flow, acuity and staffing of both SDEC and ED. Senior leaders were satisfied with the staffing levels within the department.

There were not enough nursing staff to safely treat children. The paediatric ED aimed for 4 registered nurses in the day and 4 at night. On 26 November 2025 there were 2 paediatric nurses on shift until 1pm which included covering paediatric triage. On 25 November 2025 they had 3 trained nurses. The department was mostly staffed with registered paediatric nurses but also had some adult nurses who had completed paediatric competencies who supported within the department. We were told they regularly were short staffed. Following the inspection, managers allocated a further 2 registered nurses to paediatrics. A member of staff told us training opportunities were limited due to the staffing levels.

Managers had stopped using agency nursing staff to cover shortfalls. Agency was only used when they needed a 1-to-1 for patients with mental health concerns. Leaders mostly used bank nursing staff to cover shifts, but often shifts were not filled. They heavily relied on bank staff to increase numbers while the department was crowded. Bank usage in ED between 24 November 2025 and 7 December 2025 for nursing staff was around 1000 hours a week and paediatric nursing was 35 hours. SDEC used 207 nursing bank hours the week commencing 1 December 2025 which had increased from the previous week which was 57 hours.

Advanced nurse practitioners, nurse practitioners and GPs staffed the UTC area. This was in line with establishment.

The service did not have enough substantive medical staff to keep patients safe and relied on regular locum doctors to reduce the risks and increase the safe staffing levels within the department. Consultant staffing in the ED was in line with the Royal College of Emergency Medicine (RCEM) which recommended 16 hours consultant presence every day. There were vacancies with middle grade resident doctors as there had been fewer staff assigned from the deanery. Normally they were given 12 registrars, but they had been given 3.6 whole time equivalents; this correlated with a deterioration in their performance. Measures were put in place by the directorate working with divisional management to recruit alternative doctors to plug these gaps. There had been an increased spend on locum registrars, which ensured seniority overnight.

Where gaps remained, consultants stepped down to cover these roles overnight to ensure safe staffing. Despite this, there were long delays in patients being reviewed overnight due to medical staffing. The department model was 6 doctors overnight to be safe, but they aimed for 10. They aimed to have at least 4 registrars on overnight, this also included Advanced Clinical Practitioners (ACP). We saw locum usage was high between July and November 2025. They used between 23 and 33 whole time equivalent shifts per week including ACPs, consultants and resident doctors. They had recently implemented in-house rota coordinators to take responsibility from the medical staffing team to reduce the number of errors within the rota which led to short staffing. In October 2025 they had produced a standard operating procedure for gaps in the ED medicine night rota.

Following the inspection, the trust added in an additional 2 consultants to support ED and SDEC. To reduce the workload and delays overnight they also introduced an additional 2 resident doctors for a 6pm to 2am shift as a regular measure. The service always had a consultant on call during evenings and weekends. We were told they mostly did not leave before 2am. Prior to the inspection, there was a 9am to 5pm additional consultant shift on a Monday and Tuesday to meet increased demand. Following the inspection, the service also implemented an additional 11am to 7pm consultant shift 7 days a week and made the 9am to 5pm shift 7 days a week.

There was a senior decision maker allocated overnight when consultants were not on shift. When locum doctors were needed, they had training in emergency medicine. The service had recently recruited 3 consultants and were lining up jobs for trainees. They used between 1 and 4 ‘surge’ doctors based on demand and capacity between 9am and 5pm covered by locum doctors. They had 4 ACPs in the department but the supervision requirement was intensive as they were new to their role, but the long-term strategy was to support the resident doctors. There were also physician associates who assisted in the department as tier 1 doctors.

There were medical consultants who covered the ED 8am to 9pm and then there were 2 medical registrars based in the ED and SDEC overnight and a medical on call consultant off site overnight from midnight to 7am. They told us they worked closely with their ED colleagues.

Staffing of doctors in the PED was in line with the RCEM guidance. Within the PED, there were 7 paediatric consultants who covered from 8am to 12am. After midnight, the cover was provided by a rotational registrar. There were 8 paediatric advanced clinical practitioners (ACPs) who worked in the department to assist the doctors.

The trust had recently commissioned a review of medical staffing in ED. This identified a requirement to increase established medical workforce which was being covered through temporary staffing. This was being addressed through the trust’s clinical fellowship programme and active recruitment of consultants. They had recruited eleven clinical fellows between July and September 2025. Staff told us it was a good clinical fellow training programme, and they were working to ‘grow their own.’

Medical staff received training monthly. They told us there was great integration into the team when they started, they had a good induction and supernumerary period and felt no pressure to get onto the rota.

“There was a 3-year ACP trainee pathway, but staff told us this was not always supportive. The programme was structured and in line with the nationally recognised framework. Trainees were given supernumerary time in line with the programme.” Staff did not always receive the support they needed to deliver safe care. Staffing levels were not always in line with the planned levels, and this meant staff could not deliver safe care for their patients. At the time of the inspection, the practice education team had been redeployed into clinical roles in the department until January 2026 to boost the staffing numbers; this impacted on the support and training they could give to the department.

All nursing staff were put into teams which sat under the matron. They were led by a band 7 senior nurse and comprised of band 6 and band 5 nurses and band 3 healthcare assistants. The band 7’s and 6’s were responsible for completing appraisals for their team; this was the same in the PED.

Appraisals were not up to date. Data showed 42% of appraisals for PED staff were completed and 65% for ED staff. Managers told us they did not have time to complete appraisals due to time constraints in the departments. They had recently restructured the band 7 teams to make them smaller and more achievable to complete tasks such as appraisals. There was no action plan in place to improve appraisal rates.

All new starters underwent an induction and had a supernumerary period. Newly qualified nurses were provided with a competency booklet, and training was supported by the practice education facilitator (PEF) team. They had an in-house new starters week and clinical skills courses to ensure competence. Although there were no paediatric trained nurses in the PEF team. Staff linked in with the PEF on the children’s unit when needed.

There was poor compliance with life support training. Compliance with life support training was 74.7% for adult life support and 73.5% for paediatric life support. Managers told us the ED nursing workforce had sufficient trained staff to provide the requisite competence and skillset required for the ED. Their electronic roster system ensured there were enough people who were trained in the department on shift. The department had received funding for trauma nursing core course and had 19 staff members attending this by April 2026.

All staff who undertook triage in key areas had completed formalised triage competencies; this was evidenced through the electronic roster system. There were 4 staff members in the department who were triage trainers and were looking to get 3 more staff trained as trainers to keep up the compliance in the department.

There were 6 medical assistants in PED; they were 4th year medical students. They assisted with bloods, observations, cannulas and clerking patients prior to senior reviews.

There was an ED pharmacy service present 5 days per week as of November 2025. The pharmacist wanted to increase the presence in the department and include a pharmacy technician. The RCEM recommends 1 as a minimum to provide supporting roles and assist in medicines management. The pharmacist had completed a time in motion study and noticed nurses spent on average 25 minutes looking for patient medication. This could be significantly reduced if there was a pharmacy technician available.

Staff were noticeably busy and worked under pressure when the department had higher numbers of patients or when people required close supervision. There was a good degree of support and mutual respect among staff working in the department but they were visibly stretched and unable to provide good care.

The psychiatric liaison team provided some training to the departmental staff. This included training on the Mental Health Act and Mental Capacity Act for trainee doctors, mental health awareness as part of induction and ad hoc sessions, such as a recent one of managing people expressing suicidal ideation.

The systems and processes did not always operate effectively to assess and manage the risk of infection. There was not an effective approach to assessing and managing the risk of infection, which was in line with current relevant national guidance. However, our observations of staff conduct during our inspection showed that they managed infection prevention and control well.

Managers audited compliance with infection control practices including hand hygiene, care quality assurance and cleaning. Audits results varied. Hand hygiene results which were peer assessed were 100% for September and November 2025 but for the same time period self-assessment results were 59.7% and 22.5% respectively. SDEC hand hygiene results for October and November 2025 were 98.7% for both months. There were environmental audits completed in SDEC, the results were above 90% for both October and November 2025. In ED the environmental audit results for both October 2025 and November were below 90%. There were no action plans associated with the audits to improve compliance.

We saw a trust wide commode audit was completed in March 2025 but it was not clear which results were for ED. However, staff told us the result of a commode audit needed improvement and had been discussed with them at handover. They told us a focus had been made on ensuring the commodes were cleaned properly.

A linen audit was completed in September 2025, results showed PED was 68%, ED was 55% and ARC was 27%; we saw an action plan for the trust but it was not clear this had been taken on board by the department to drive improvement.

People were not always protected as much as possible from the risk of infection however on inspection were found the premises and equipment were kept visibly clean and had suitable furnishings which were mostly well maintained. Although we saw the chairs outside triage and benches in resuscitation had the foam coming out of them which meant they could not be effectively cleaned. We saw housekeepers in all areas working hard to keep the areas clean. We were told the housekeepers had weekly audits and these results were fed back by their managers, and they were told where improvements were needed.

There are clear roles and responsibilities around infection prevention and control (IPC). The infection prevention and control team supported the department. There was enough personal protective equipment (PPE) available for staff to equip themselves for the different levels of protection. Staff followed infection control principles including the use of PPE.

Most staff we saw followed IPC principles including the use of personal protective equipment. We saw staff washed or sanitised their hands in line with the 5 moments for hand hygiene. However, we saw 3 members of staff who were not following uniform policy to be bare below the elbow and were wearing rings with stones in.

The PED did not do all they could to prevent the spread of respiratory illness. For example, we were told children with respiratory symptoms were swabbed to determine if they had influenza for example and went back into the waiting room and mixed with other children whilst they were waiting to be seen.

Staff received training about IPC and hand hygiene training during their initial induction and annual mandatory training. Training data showed that 92% of staff, had completed IPC level 2 training.

Side rooms were available when isolation was required, and staff told us how they would manage the risks associated with transmittable infections. The information staff told us was in line with best practice. We saw an example where a child presented with measles and a space was found in the department away from vulnerable staff who were pregnant. This was discussed between the wider department, and a workable solution was found. However, we found that patients who were at risk of developing infections, such as patients with neutropenia, were not always isolated whilst waiting to be seen in the waiting room.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. There were significant shortfalls in the management of medicines.

Staff did not always follow systems and processes to prescribe and administer medicines safely. Medicines were prescribed on paper charts. However, staff did not always complete medicines records accurately. We looked at 10 medicine charts and found 3 were not completed in line with national guidelines. We found medicines prescribed and not given on SDEC and blank boxes on the chart. The patient notes documented that the patient was unable to swallow, but this was not documented on the medicine chart and no alternatives had been sourced. We found another chart had 2 medicines prescribed with no time to be given written on the medicine chart and another patient went 3 days without their regular medication being prescribed. The pharmacist told us they were a prescriber so were able to rectify 90% of prescribing errors during their reconciliation of people’s medicine charts.

Patients did not always receive time critical medicines (TCM) on time. The potential delay to patients receiving TCM was on the risk register. The pharmacist told us the staff did not do well identifying TCM and they wanted to create a time critical pathway to ensure medicines were highlighted. Data from the RCEM TCM Quality Improvement Program between May and September 2025 showed of the 95 patients reviewed, 34 patients who had Parkinsons were not identified as on time critical medicines. Staff told us the long stay pathway identified the need for time critical medicines, but this was not always completed. We were told there was a RCEM Quality improvement programme underway and identification of the time critical medicines had improved. There were posters in the waiting areas and ED about TCM and conditions and highlighting to patients to speak to staff if they had these. Patients with TCM were given an orange card which highlighted to staff they needed medicines to be given on time.

Pharmacy conducted audits of the medicines and how they were stored including a safe and secure medicines audit. The pharmacist told us there was poor compliance and common themes included not monitoring the fridge and ambient temperatures, and medicines were not always put in the right places. They fed the results back in their monthly ED pharmacy meeting and actions were assigned to improve compliance; improvements in compliance were yet to be seen.

Emergency medicines and checks were not well completed. Emergency medicines and equipment were available. All expiry dates checked were in date. There were tamper evident seals in place to ensure they were safe. However, staff did not always record the daily and weekly safety checks on emergency medicines and equipment to ensure they were safe to use if needed in an emergency. We saw this was picked up in the ARC ward storage audit from September 2025. There was an action plan, but it was not clear who was responsible, how it had been communicated and what date they needed to improve compliance by. We saw on our inspection that these checks were still not being completed.

Improvement was needed to the arrangements for the safe management, use and oversight of controlled medicines (CDs). Checks were undertaken and recorded by 2 staff twice a day. We saw this undertaken in Paediatric ED. Checks of CDs showed they were within date and stock balances were correct. CDs were audited by pharmacy quarterly. Results showed improvements were needed. The pharmacist told us results were fed back to the matron and then communicated by email. They audited the CD’s quarterly. There was no overall percentage for these audits displayed. There was no clear date on the CD audits and actions were not assigned to someone responsible or with a timeframe for completion. We were not assured these were communicated to the teams as staff we spoke with did not recall these audit results being shared.

Medicines storage checks were not always completed in ED. Records of medicine fridge temperatures and ambient room temperatures in the ED were not always recorded daily and were not always within a safe range for medicine storage. We found that when they were out of range, they were not always acted upon. For example, in September 2025 the fridge temperature in majors was out of range on 9 days and the ambient room temperature was out of range on 16 days. We saw action was taken on only 1 of these days to ensure medicines were stored safely. The pharmacist told us communication had been sent to the matron and practice education facilitators regarding this, but improvements were yet to be seen. Audits for September 2025 showed checks not being completed or actioned. There were actions documented in the audit, but not clear if these had been communicated with staff and who was responsible for ensuring an improvement in compliance. Fridge and room checks were completed daily in the PED.

Allergy statuses of patients were routinely recorded on all medicine records seen and a red wrist band was worn by patients to identify the medicine causing the allergy. This meant that allergies were highlighted, and medicines could be prescribed safely. Staff told us there had been a real push on this following an incident where a patient who was allergic to a medicine was given it. We reviewed 2 incidents in prior to the inspection where patients allergy status was not checked or documented prior to giving medicines as per the trust policy which had been updated. We saw emails were sent to all staff to remind them of the process including a ‘making it better alert’.

The service completed an audit of allergy status and saw results improved between April and October 2025. In October 100% of allergies were noted and the number of sources had improved and 84.6% were checked with 2 or more sources; this had improved since April where only 28.3% were checked with 2 or more sources. Although we also saw a documentation audit for September 2025 which showed the medicine allergy box of the nursing paperwork was only completed 30% of the time. There was no action plans associated with these audits therefore could not ascertain what staff were doing to improve their compliance.

The dedicated ED pharmacist undertook medicines reconciliation to ensure people’s medicines were appropriately prescribed, supplied and administered in line with guidance.

Medicines were stored safely in ED and PED within a locked and automated medicine cabinet. It required card and fingerprint access. The system ensured good stock management. Pharmacy team were able to run a daily report and look at the usage of medicines and see what required topping up. The fridge was also linked to the automated system.

Staff followed national practice to check patients had the correct medicines when they were admitted, or they moved between services. Medicines history was taken on admission to ED by the medical staff. This information was recorded in all the patients records we reviewed.

There were patient group directives (PGDs) used in certain areas of the ED. All band 6 and 7 paediatric nurses and ENPs in see and treat could administer against PGDs for pain relief and inhaler medication so these could be given without a prescription and review from a doctor.

The pharmacist had been involved in a few quality improvement projects. One included proving the impact of pharmacy in ED which led to a full-time pharmacist being employed into ED. They told us there was a culture change needed with medicines practice in the ED, but the leadership team were on board with this, and the team were going in the right direction.

The pharmacy audited the prescription charts in September 2025 and produced a report in December 2025. Results were mixed and it demonstrated that prescribing practice did not always meet the standards set out in the medicine policy. It had 6 recommendations and an action plan to complete.

Where people were identified as high risk of severe illness or death from sepsis, broad spectrum intravenous antibiotics were given within 1 hour of calculating the NEWS2 or PEWS score on initial assessment in the ED or PED. We saw use of the sepsis 6 tool. Audits showed antibiotics were not always given within 1 hour of highlighting potential sepsis.

There were pre-packed supplies of the most prescribed take home medications in ED to reduce the amount of time patients had to wait to be discharged. In PED, to take out medicines (TTO’s) were prescribed and the families took them to the hospital pharmacy for them to be dispensed.

Staff had protocols for administering rapid tranquilisation.