Fairfield General Hospital

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• 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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

There was routine use of corridor care which risked patients’ safety, privacy and dignity and staff’s ability to provide safe care. Staff practice did not always reflect the policies and procedures for managing patients nursed on the corridor.

The service did not always make sure there were enough qualified, skilled and experienced staff. Not all staff had completed required mandatory training, including life support training. The service did not always have effective processes for the management of sepsis.

Staff did not always follow guidance around hand hygiene and use of personal protective equipment. Routine audits showed poor staff compliance in some infection control standards. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

However, staff understood how to protect patients from abuse. Premises and equipment were clean and well-maintained. The service managed safety incidents well and learned lessons from them.

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.

We scored the service as 3. The evidence showed a good standard. The service had a positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to identify and embed good practice.

Staff knew what incidents to report and how to report them. They raised concerns and reported incidents on an electronic incident reporting system, in line with the trust’s patient safety incident response policy. Staff used the patient safety incident response framework (PSIRF) to aid learning and improvement. Incidents were reviewed and investigated by staff with the appropriate level of seniority, such as clinical leads and senior nurses.

Staff received feedback following the investigation of incidents. Staff met to discuss the feedback and look at improvements to patient’s care during daily safety huddles, shift handover meetings and during routine departmental, directorate and divisional staff meetings so shared learning could take place. Learning from incidents was also shared through hospital-wide alerts and bulletins, event learning summaries, hot topic briefings and monthly newsletters to aid learning and improvement.

The patients and relatives we spoke with told us they felt safe and did not have any concerns around safety incidents.

There had been 1,790 incidents reported by the urgent and emergency services across the hospital between February 2025 and January 2026. Most reported incidents were categorised as no or low harm. The most frequent reasons for incidents were patients missing or leaving without being seen, treatment issues or delays and falls, slips and trips.

There had been no never events reported by the urgent and emergency services during the 12 months prior to our inspection. Never events are serious safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious harm or death but neither need have happened for an incident to be a never event.

There had been 2 severe harm incidents and 1 patient death reported by the urgent and emergency services between February 2025 and January 2026. We looked at 3 recent incident investigation reports. They all showed the incidents had been appropriately investigated and action plans were put in place to aid learning and improvement.

Patient deaths were reviewed and shared with staff as part of routine mortality and morbidity reviews to aid learning and improvement.

Staff understood duty of candour. They were open and transparent and gave patients and their relatives a full explanation if and when things went wrong. Records showed formal duty of candour had been undertaken in a timely manner for all eligible incidents during the 12 months prior to our inspection.

We scored the service as 2. The evidence showed some shortfalls. The service worked with people and healthcare partners to establish and maintain safe care systems and continuity of care. However, there was routine use of corridor care which risked patients’ safety, privacy and dignity and staff’s ability to provide safe care. Staff practice did not always reflect the policies and procedures for managing patients nursed on the corridor.

There was routine use of corridor care which risked patients’ safety, privacy and dignity and staff’s ability to provide safe care. We found gaps in care records around intentional rounding observations for patients nursed on the corridor in the emergency department (ED). We also found staff practice did not always reflect trust polices for managing patients nursed on the corridor. However, we found most corridor care patients received safe care and treatment and there had been no significant patient harm incidents reported specifically relating to ED corridor care in the 12 months prior to our inspection.

The trust’s policies relating to temporary escalation spaces (TES) and the local emergency department (ED) standard operating procedure (SOP) for patients nursed on the corridor provided guidance for staff on how to manage patients in non-designated clinical spaces, such as corridors or TES.

The senior nurse in the ambulance rapid assessment and treatment (RAT) area completed an emergency department TES risk assessment, in consultation with the band 7 shift nurse in charge, to determine if patients were suitable for corridor care. The TES risk assessment stated patients with infection prevention and control risks requiring isolation and patients requiring high dependency care were excluded from corridor care.

Staff completing the ED TES risk assessment were also required to tick if the patient had any identified risks, such as patients with elevated national early warning scores (NEWS), mental health needs, falls risks, those requiring oxygen or enhanced observations and patients unable to state their needs were not suitable for corridor care. Patients identified with these risks were assessed by the senior nurse in charge to determine their suitability for corridor care. Nursing staff told us they could also seek medical input if they were unclear about a patient’s suitability for corridor care but this was not always routine practice.

We found TES assessments had been completed in each of the corridor patient’s records we looked at. The trust reported that patients with cognitive Impairment and mental health needs were within the scope of corridor-based care and the emergency department risk assessment (January 2026) did not exclude these patients from corridor care. However, we identified at least 1 elderly patient on the corridor who displayed cognitive impairment symptoms who may not have been suitable for corridor care during our inspection. We saw this patient attempted to stand up unaccompanied and staff had to be prompted to attend to the patient. We saw a healthcare assistant had subsequently been assigned to observe and monitor this patient. We found 1 corridor care patient had an elevated early warning score who may not have been suitable for corridor care. We also identified a patient with mental health needs that had been nursed on the corridor overnight, but we saw this patient had been transferred to a designated mental health cubicle on the morning of our visit.

The trust’s policies included contradictory or unclear information about patient eligibility for temporary escalation spaces or corridor care spaces in different areas of the hospital. The policy included more stringent inclusion criteria on the inpatient wards compared with the emergency department. For example, patients requiring oxygen, those at risk of falls or those with mental health needs were excluded for TES spaces on the wards but were eligible for ED corridor care. The trust reported the patient inclusion criteria for temporary escalation areas in ED differed from the ward areas because staff visibility was enhanced on the ED corridor

An ED corridor care risk assessment for oxygen therapy on corridor was in place and this included guidance for staff around managing patients requiring oxygen, including the use of portable oxygen for patients nursed on the corridor. Whilst we did not see any corridor care patients receiving oxygen during the inspection, staff told us patients requiring oxygen could be nursed on the ED corridor during periods of high capacity and demand.

The local SOP for ED patients nursed on the corridor provided instructions for staff around communication with patients and relatives and stated information signs had been placed on the corridor. We spoke with 5 patients and the relative of another patient who was being nursed on the ED corridor. They told us they had been assessed by staff and understood the next steps in their care and treatment (such as awaiting bloods or diagnostic imaging). However, they told us they were given limited information about why they had been placed on corridor care and had not been given clear information about how long they would remain on the corridor or in the department.

The local SOP for ED patients nursed on the corridor provided instructions for staff around maintaining patient’s privacy and dignity and stated privacy screens were available and must be utilised. The corridor care patients we spoke with and observed during the inspection had not routinely been provided with privacy screens. However, we saw patients were moved to a designated cubicle to maintain privacy and dignity when undertaking clinical assessments or providing personal care.

The local SOP for ED patients nursed on the corridor stated staff must ensure nursing documentation was complete, including intentional rounding charts. Care records included an ED patient safety checklist, which staff were required to complete hourly for the first 6 hours of a patient’s arrival. This was then followed by two-hourly intentional rounding checks until the patient had been discharged or transferred from the department.

We looked at 5 records for corridor care patients and found the ED checklists and intentional rounding observations had not always been completed or documented appropriately. Staff told us they were not always able to update the ED checklist records during busy periods but they recorded the relevant information in the daily nursing notes. We saw some evidence of this in the records we looked at.

We found other sections of the care records for corridor care patients had been completed appropriately, including timely observations to identify deteriorating patients, nutrition and hydration, pressure ulcer and falls risks and for safeguarding concerns. We also saw good practice around timely monitoring and completion of intentional rounding observations for a patient with mental health needs who had been nursed on the corridor.

Staff carried out a risk assessment prior to commencing corridor care and we saw evidence these were completed appropriately during our inspection. This included assessing the suitability of the designated escalation spaces, whether appropriate staffing was available to maintain a 1:5 nurse to patient ratio and the provision of oversight from the nurse in charge, shift coordinator and site management team.

The urgent and emergency care services had operational policies and pathways that provided guidance for staff around admission, transfer and discharge processes. Most patients and relatives we spoke with told us they were kept informed about their care and treatment and understood who was reviewing their care.

The service had clear pathways for adults and children presenting in the emergency department as well as for pregnant women and patients with mental health needs.

The service had effective streaming pathways so patients presenting in the emergency department with certain low risk conditions could be assessed, diagnosed and treated by avoiding admission to an inpatient ward, and if appropriate, could be discharged home the same day.

Children presenting with high risk or life threatening conditions that required admission to a ward were assessed, stabilised and transferred to the other local hospitals that provided inpatient children’s services or to regional specialist children’s hospitals. The emergency department had an arrangement with the North West and North Wales paediatric transport service (NWTS) for the transfer of critically ill children to specialist children’s hospitals.

There were pathways in place for the transfer of patients to other NHS hospitals for treatments not provided at this hospital. This included severe burns, children with eating disorders, patients with acute dermatological conditions, adult patients with potential acute general surgical disease, those requiring plastic and reconstructive surgery and for vascular emergencies. There had been 22,018 patient transfers resulting in inpatient admissions at other local hospitals between February 2025 and January 2026.

Service partners and stakeholders (such as mental health, ambulance, community and acute NHS healthcare services) spoke positively about the systems and pathways in place for the admission, transfer and discharge of patients across the urgent and emergency care services.

We scored the service as 3. The evidence showed a good standard. The service concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff could access policies for the protection of adults at risk of abuse and neglect and for safeguarding children. These provided guidance for staff on how to identify and report any safeguarding concerns, including making referrals internally and to external agencies, such as local authority safeguarding teams.

Staff told us they had received safeguarding training and understood how to identify abuse and report safeguarding concerns. They told us learning from any reported safeguarding incidents was shared as part of daily huddles, handovers and during routine staff meetings. Patients told us they felt safe and understood how to raise any safeguarding concerns they had with the staff.

Staff completed training specific for their role on how to recognise and report abuse, in line with current intercollegiate guidance for adults and children.

We identified a regulatory breach in safeguarding training compliance during our previous inspection in August 2022 where we identified training compliance as low as 35% for adult safeguarding training and as low as 65% for children’s safeguarding training. We found improvements had been made during this inspection.

Most staff across the urgent and emergency services had completed adult and children’s safeguarding training (level 1,2 and 3). Overall training compliance for nursing and support staff was better than the hospital’s training compliance target (90%). Training compliance for medical staff was better than the 90% hospital target for all adult and children’s safeguarding training levels, except for level 3 children’s safeguarding training. Records showed most medical staff (83%) had completed level 3 children’s training but the hospital’s compliance target of 90% had not been achieved.

Training in the Mental Capacity Act, deprivation of liberty safeguards (DoLS) and female genital mutilation was incorporated into the adult and children’s safeguarding training. Records showed 97% of staff across the urgent and emergency services had completed preventing radicalisation basic awareness training and 96% of staff had also completed prevent WRAP e-learning training. Staff also received additional training as part staff inductions and team development days, including mental health awareness, recognition of mental health presentations, and appropriate initial responses within the emergency department.

There were systems and processes in place to identify and manage risks associated with patients that had multiple attendances within the emergency department (frequent attenders). This included monthly reviews of patients who frequently attended the department and routine internal and external multidisciplinary meetings involving local authority, mental health, safeguarding and Police to review and manage patient risks and to identify ways to provide additional support for these patients. The hospital had also appointed a vulnerable persons ED nurse who was responsible for monitoring frequent attenders, safeguarding issues and supporting embedding of learning / actions for adults and children,

The service had clear processes for patients with mental health needs attending the emergency department. The service employed clinical nurse specialists and paediatric liaison nurses to assess children and young people attending the department. Doctors could access support from an on-call child and adolescent mental health service (CAMHS) consultant.

Staff had guidelines for children and young people presenting in acute mental health crisis requiring care and treatment to support their mental health and emotional well-being. Young people presenting in mental health crisis were referred to the mental health trust and the local authority for support and follow up, as necessary.

The service’s electronic system flagged if an adult or child was thought to be at risk or had a known safeguarding history. Staff understood how and when to check the child protection information sharing system (CPIS) and alerted staff if the child was known to have a child protection plan in place or was a looked-after child. There was a clear process for staff to refer child patients attending the department to general practitioners, social workers and health visitors.

There had been 40 safeguarding incidents reported by the hospital relating to urgent and emergency care services between January 2025 and January 2026. Records showed appropriate actions had been taken to safeguard vulnerable people.

The adult patient restrictive interventions policy provided guidance for staff on the use of restraint. Members of security staff were available to attend to the emergency department during the day, if required. Security members of staff did not complete therapeutic observations, but they would support restraint of patients. Security members of staff received training in the use restraint.

The emergency department had a process for supporting patients subject to section 136 of the Mental Health Act. When a person attended under Section 136 Mental Health Act, they remained the responsibility of Police whilst waiting to be assessed. This assessment was coordinated by an approved mental health professional (AMHP).

Staff could access support and guidance from the hospital’s safeguarding team, which included safeguarding leads for adults and children. The safeguarding leads had completed the higher level of safeguarding training (level 4 or above).

The safeguarding leads attended routine meetings within the urgent and emergency care services and were involved in serious incident and patient death reviews. The safeguarding leads also attended routine hospital wide safeguarding steering group meetings and trust-wide safeguarding committee meetings that took place every 3 months to review incidents and identify learning and improvement.

We scored the service as 2. The evidence showed some shortfalls. The service worked with people to understand and manage risks. Staff provided care to meet most people’s needs. However, the service did not always have effective processes for the management of sepsis.

The service had policies, guidelines, pathways and screening tools that were based on national guidance for the management of adult and child patients with suspected sepsis, including neutropenic sepsis. Staff received training on how to identify and manage sepsis in line with policies and national guidelines. Records showed 80% of medical staff, 100% of advanced care practitioners and 89% of nursing and support staff had completed sepsis training across the urgent and emergency services.

We looked at 3 records for patients with suspected sepsis. We saw evidence antibiotic treatment was commenced within an hour in 2 of these records. We found the sepsis care pathway records and nursing and medical staff notes were not fully complete or up to date in all 3 records we looked at.

The hospital did not provide sepsis audit data specifically for the urgent and emergency care services. However, a hospital-wide sepsis audit undertaken during July 2025 and October 2025 showed mixed compliance against 8 audit indicators when compared with overall trust averages. The hospital performed better than trust average in 4 of the 8 indicators in the July 2025 audit and performed worse than trust average in 5 of the 8 audit standards in October 2025.

The sepsis audit showed this hospital achieved good compliance for some audit indicators, such as national early warning score (NEWS) within 1 hour of patient arrival and appropriateness of antibiotics administered. However, the audit also identified poor staff compliance in the audit indicator for patients screened for sepsis (58% in July 2025 and 58% in October 2025). The July 2025 sepsis audit data also showed 100% compliance was achieved for appropriate review for patients with NEWS 7 or above, whereas only 33% compliance was achieved in the October 2025 audit.

Patients attending the emergency department were triaged by a nurse who asked routine questions using a recognised triage tool to determine the nature of their ailment. There were a number of trained triage nurses so additional nurses could be allocated to triage duties during busy periods.

Triage nurses were trained to assess both adults and children. Patients were triaged and streamed to the appropriate route depending on the severity of their ailment. The initial patient triage process was recorded electronically. Patients underwent a nursing assessment triage, which included undertaking vital observations, electrocardiogram (ECG) tests, bloods and cannulation and to check for specific conditions so patients could be promptly placed on the appropriate care pathways.

Staff used paper based patient clinical assessment records and care pathways to document risk assessments, care plans, observations and daily medical and nursing notes. Most patients told us they had received triage assessments on arrival and staff carried out regular observations of their care.

Patient records included risk assessments, such as for falls, pressure ulcers, nutrition and hydration, moving and infection control risks. Most children and adult patient records we looked at included up to date risk assessments and showed that nursing and medical assessments were carried out in a timely manner and documented correctly. Observations were well recorded and the observation times were dependent on the level of care needed by the patient.

Staff used recognised adult and paediatric early warning score systems and carried out routine monitoring based on patients’ individual needs to ensure any changes to their medical condition could be promptly identified. If a patient’s health deteriorated, staff were supported with medical input when required. Care records we looked at showed most patients received regular and timely observations and were escalated appropriately when required.

The urgent and emergency services mainly used paper based patient records. We looked at 27 patient records across the urgent and emergency services. We found most records were structured, legible, complete and up to date, with few errors or omissions.

Routine patient record audits took place to check for accuracy and completeness. The quality matrons carried out a monthly quality assurance review (QAR) audit which sampled 5 records across the urgent and emergency care services. QAR audit records showed monthly compliance ranged between 79% and 89% between January 2025 and December 2025. However, the trust compliance target of 90% had not been achieved. The QAR audit data also showed an improving trend in compliance. The average compliance during July to December 2025 was 87%, compared with average compliance of 82% during the period between January 2025 and June 2025.

An ED documentation audit (April 2025) also assessed compliance against 35 standards. The audit showed compliance above 95% (green) had been achieved in 11 of the 35 standards and partial compliance between 64% and 94% (amber) had been achieved in 22 standards. The audit highlighted poor compliance in the 2 remaining audit standards, relating to documenting patient’s valuables (7%) and patient’s resuscitation status (40%). Audit findings had been shared with staff to aid learning and improvement.

Nursing and medical staff handovers took place during daily shift changes and these included discussions about patient needs and any staffing or capacity issues. Shift changes and handovers included the necessary information about patient risks and needs.

A monthly quality matron review involved observing handovers, safety huddles and patient care and reviewing a sample of patient records. Quality matron review records between June 2025 and October 2025 showed mostly good compliance had been achieved in relation to staff handover processes and patient care and treatment.

The care records for patients with mental health needs we looked at showed 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.

Staff told us they would assess if a patient with mental health needs required 1:1 observation and if necessary, they could request additional staff to do this via a private company who would generally be available within 1 hour and remain in place until no longer required. The private security staff had specialist training which included MAYBO (conflict management and personal safety training accredited by the Restraint Reduction Network).

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The ED, SDEC and UTC areas were well maintained, free from clutter and provided a secure environment for treating patients. The UTC was located across the corridor from the emergency department. The SDEC ward was located one floor above the emergency department. The services were easily accessible, including for wheelchair access. However, the SDEC ward was not clearly signposted for patients and visitors.

The ED had separate points of entry for ambulance patients and self-presenting patients attending the department. Patients conveyed by ambulance were assessed and triaged in the rapid assessment and treatment (RAT) area. The waiting area for self-presenting patients in the emergency department could accommodate up to 30 people and had an adult triage room and treatment room (for nursing and medical assessments).

The ambulance RAT area had 4 cubicles. There were two additional ambulance cohort cubicles next to the RAT area for ambulance crews awaiting assessment and these had curtains to maintain patient privacy and confidentiality.

The ED also had separate resuscitation and major injury areas. The ED had 10 designated corridor care spaces. This included 9 clearly marked spaces in the major injuries area corridor and 1 designated cubicle that corridor care patients could be moved to for privacy / dignity when undertaking clinical assessments or provision of personal care.

We saw up to date risk assessments had been undertaken to identify and mitigate fire and health and safety risks associated with the corridor care spaces. We saw patients nursed on the corridor were placed in sight of the nurses station in the majors and 1 nurse was allocated for every 5 corridor patients.

Adults and children used the same entrance and reception area when arriving in the department. However, there was a separate paediatric urgent treatment centre (UTC) area, which included a segregated waiting room, triage area and 5 assessment cubicles. There were sufficient toilet facilities in the department and these included disability access and changing facilities for babies and children. The UTC and SDEC areas provided a suitable environment for care and treatment and had waiting room capacity for up to 30 people in each area.

We identified a regulatory breach in relation to the facilities for assessing patients with mental health needs during our previous inspection in August 2022, we found improvements had been made during this inspection.

Mental health risk assessments were in place and these included mitigations and controls for key risks including suicide and ligature risks. The department had ligature-free emergency pull cords in place. We found these were missing in the toilet rooms in the main waiting area. We raised this with the lead nurse during the inspection.

The department had a dedicated room for assessing patients with mental health needs. This room met Psychiatric Liaison Accreditation Network (PLAN) standards. The room had one door, which opened outwards and had a viewing panel that could be closed. The room was furnished minimally with heavy furniture. Staff had completed a ligature risk assessment of the room.

Staff told us equipment was readily available and any faulty equipment could be replaced promptly. Single use items and consumables were stored safely and were kept within expiry dates. Equipment was serviced by the hospital’s maintenance team under a planned preventive maintenance schedule. Staff told us they received good and timely support.

Suitable equipment was available in all areas including appropriate equipment for children. The majority of equipment we saw was clean, well-maintained and within service and calibration dates. However, we found some minor items such as screen monitors with missing or expired service dates.

Maintenance records showed most equipment in the emergency department (86%), UTC (92%) and SDEC (96%) areas had been suitably maintained and serviced. The service reported following the inspection that all outstanding monitors and modules had been serviced and the remaining overdue items were flowmeters and suction regulators that had been scheduled for servicing during February 2026.

Guidance for staff in the event of a major incident was available and staff were aware of how to access this information when needed. This included guidelines for dealing with chemical, biological, radiological, nuclear or explosive (CBRNE) hazards. We saw the department had suitable decontamination facilities. We found CBRNE equipment checklists were not kept up to date but saw CBRNE equipment and personal protective equipment had been suitably maintained and was readily available for staff in the event of a CBRNE incident.

Staff routinely took part in CBRNE simulation exercises. A major incident tabletop exercise was also carried out in July 2025, focusing on the hospital’s pandemic response in the event of a high impact infectious disease outbreak.

The regional NHS ambulance trust had conducted an annual audit of the site’s CBRNE processes and decontamination facilities during October 2025. The audit showed the service demonstrated good compliance with most of the audit standards. An action plan was in place to address the area of partial compliance, which related to the recalibration of radiation dose monitors. The service reported this had been arranged with the hospital’s medical devices team.

The service reported they had followed previous NHSE guidance which stated these radiation monitors did not need recalibration. This guidance had since been updated and recalibration had been arranged with the hospital’s medical devices team following the recommendations from the October 2025 ambulance service audit.

Emergency resuscitation equipment for adults and children was available in all the areas we inspected and this was routinely checked by staff. We saw that daily, weekly and monthly equipment check logs were mostly complete and up to date, with few errors or missing checks. The emergency resuscitation trolleys were tagged to minimise the risk that items could be tampered with.

The emergency department had undergone refurbishment during 2024, which included expansion of the waiting areas and ambulance assessment areas. The urgent and emergency department planned further upgrades, including additional waiting areas, treatment bays, resuscitation bays and mental health assessment rooms. Funding for the proposed upgrades had been agreed and staff told us refurbishment work was expected to commence in late 2026.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. Not all staff had completed required mandatory training, including life support training.

Most patients we spoke with told us there were enough staff to provide safe care and treatment. They spoke positively about the way staff had supported them. However, 2 patients we spoke with told us staff had not responded promptly when called during the night. Staff told us they had increased workloads during busy periods. However, most staff did not highlight any concerns around staffing levels and told us their workloads were manageable.

Nurse staffing levels were reviewed against minimum compliance standards every 6 months, based on the national safer nursing care acuity tool. The expected and actual staffing levels were displayed on notice boards in each area we inspected, and these were updated daily.

The service did not have sufficient numbers of nursing staff to ensure that patients received the right level of care.

The Royal College of Paediatrics and Child Heath (RCPCH) Facing the Future - standards for children and young people in emergency care settings (October 2025) stated emergency departments treating children must have at least 2 registered children’s nurses on each shift.

We found the service did not always meet the RCPH facing the future guidelines. We found there was 1 paediatric trained nurse and 1 adult nurse in the paediatric urgent treatment centre area on the first day of our inspection and 2 adult nurses on the second day of inspection. The adult nurse was responsible for triaging children attending the department. Records showed there had been at least 26 instances where there had been no paediatric trained nurses on shift in the paediatrics area and adult nurses had provided care and treatment between August 2025 and January 2026. The trust reported 91.6% of shifts had been covered by at least 1 paediatric trained nurse during this period. The trust also reported an adult nurse with training to enable triage of children provided cover during periods of sickness or absence.

The emergency department did not have a dedicated paediatric emergency medicine (PEM) consultant, in line with the RCPH facing the future standards recommendations. However, a paediatric nurse consultant had been fulfilling this role. Adult ED consultants provided consultant cover when the paediatric nurse consultant was not on shift.

A business case had been approved in January 2026 to increase staffing levels and enable the service to provide 2 paediatric nurses on each shift once the additional staff had been recruited.

The emergency department was established for 16 nurses and 4 healthcare assistants (HCA) on the morning shift and 16 nurses and 5 HCAs on the evening and nights shifts. We found the service was at least 1 nurse short on each shift during the days of our inspection.

The staffing establishment in the medical SDEC area was for 4 nurses and 3 HCA’s on the day shifts and 2 nurses and 2 HCA’s during twilight shift. The medical SDEC had 1 nurse and 1 HCA less than establishment when we visited, due to short-notice sickness. The frailty SDEC was suitably staffed with 1 nurse and 1 HCA.

The staffing establishment allowed some flexibility to cope with the number of patients attending the department, especially during busy periods. We saw staff could be deployed from other areas in the department to support ambulance triage, majors or the resuscitation area during busy periods.

We found the resuscitation area had 5 bays and was routinely staffed by 2 nurses, which did not meet Royal College of Emergency Medicine (RCEM) guidelines around staff to patient ratios in the resuscitation bays.

The RCEM guidelines stated a ratio of at least 2 registered nurses to 1 patient should be maintained during the resuscitative phase of illness or injury, such as cardiac arrest and the initial assessment of major trauma. The RCEM guidelines also stated that 1 registered nurse may care for 2 patients where patients did not require resuscitation, but were nursed in that area due to a crowded ED or had been stabilised and were awaiting further investigations or transfer to a ward.

Managers told us they would move staff from other areas to the resuscitation area to maintain safe staffing levels. However, we did not see evidence of this during the inspection.

The major injuries area had 3 high dependency care beds for patients that had stepped down from resuscitation but still required continual vital signs monitoring. We saw the 3 high dependency bays were staffed with 1 nurse supported by a HCA, which was below the recommended 1:2 staff to patient ratio.

The staffing establishment allowed for 1 nurse to support corridor care patients. Additional staff had to be sourced from bank or agency or redeployed from other areas of the department if an additional corridor care nurse was required. We saw during one of the inspection days that corridor care for 10 patients had been provided by a nurse associate and a staff nurse.

A business case for an additional 5.5 whole time equivalent (WTE) adult triage and assessment nurses and an additional 5.5 WTE nurses to allow a second nurse to support corridor care 24 hours had been submitted but had not yet been approved.

The service had 8 advanced clinical practitioners (ACPs) who worked across the emergency department and urgent treatment centre (UTC). The UTC was also staffed by a team of emergency nurse practitioners (ENPs) with up to 3 providing cover on each shift. The medical SDEC also had 2 or 3 ACP’s on site between 8am and 8pm on each shift.

We found shortfalls in ACP and ENP staffing rotas during the inspection. The UTC had 1 ACP and 1 ENP less than establishment and the SDEC area also had 1 x ACP less than establishment when we visited. However, we saw this had not impacted patient safety and the existing ACP / ENP staff were able to manage the workload.

The emergency department lead nurse told us there were 2 vacancies for band 7 nurses, and recruitment was ongoing (with 1 post appointed and the other at interview stage). There were no band 6 or band 5 adult nurse vacancies in the department. Recruitment for a healthcare assistant, band 4 nursing associate and 3 housekeeper vacancies was ongoing with potential candidates at various stages of the recruitment process. There were also 2 additional ACP’s undergoing training at the time of our inspection.

The overall average sickness rate for nursing staff (5.9%) and support staff (7.8%) was worse than the trust-wide target of 5.5% between February 2025 and January 2026. Staff turnover rate was low (less than 5%) during this period.

Cover for sickness and leave was mostly provided by the existing staff and through the use of bank, agency or locum staff. Where bank, locum or agency staff were used, managers made sure they had a full induction and understood the service. Agency spend records showed the use of agency staff had continually decreased during the 12 months prior to our inspection.

The emergency department had 10 consultants, including 9 substantive and 1 locum consultant (who mainly provided cover on weekday nights between 10pm and 6am). A draft business case had been submitted to recruit an additional 3 consultants to meet increasing demand from higher number of patients attending the emergency department.

RCEM guidelines for consultant staffing in emergency departments in the UK (2019) stated that a ratio of 1 consultant to every 3,600 to 4000 ED attendances was required for most departments. This meant the emergency department at this hospital required over 20 consultants to meet this recommendation (with over 80,000 attendances during the past 12 months).

Whilst the department did not meet RCEM recommendations for consultant establishment, we did not find evidence of patient harm resulting from consultant staffing levels.. A senior decision maker (tier 4) was on site at all times, in line with RCEM recommendations.

Consultant cover in the emergency department was available between 9am-12am during weekdays and between 9am-10pm on weekends, with on-call consultant cover available at other times. A locum consultant also provided cover during Monday to Thursday between 10pm and 6am.

There were 3 consultants on site during weekdays (including an emergency physician in charge, a consultant supporting the front door and RAT area and another supporting resuscitation / major injury areas). A consultant also supported the UTC when required. The consultants were supported by a team of resident doctors, including 12 senior / junior clinical fellows, 12 middle grade doctors and 18 GP trainees / foundation year 2 trainees. There was at least 1 middle grade and 1 resident doctor in the department at all times.

Medical cover on the medical and frailty SDEC was provided from the division of medicine medical rotas. There was at least 1 consultant on the medical SDEC during the day, with on-call cover after 5pm. A consultant geriatrician provided daily on site cover on the frailty SDEC ward. The SDEC area was also supported by a team of registrars and also resident doctors were on site up to midnight each day.

Resident and middle grade doctors we spoke with told us they received good support and could easily access consultant support when needed. The medical staff we spoke with told us their workload was manageable.

We identified a regulatory breach in mandatory training compliance during our previous inspection in August 2022, where we identified shortfalls in training compliance relating to life support, learning disabilities and autism and safeguarding training. Whilst we found some improvement had been made, training compliance for specific training topics and staff groups was below the hospital’s training completion target of 90%.

Overall mandatory training compliance was 92% for nursing and support staff and 84% for medical staff across the urgent and emergency care services.

Records showed 96 staff across urgent and emergency care services had completed dementia awareness training. Practice based educators told us dementia awareness training had recently been launched and staff compliance of 82% had been achieved in the emergency department.

Whilst staff were required to complete life support training relevant to their role, we found training compliance for specific topics and staff groups did not meet the hospital’s training completion target of 90%. Staff nurse compliance in intermediate life support training was 50% in the SDEC and 69% in the UTC areas. Medical staff training compliance in advanced life support (74%), advanced paediatric life support (71%), paediatric basic life support (59%) and adult basic life support (69%) was also below hospital targets.

We also found staff training compliance in topics such as fit (mask) testing, moving and handling and fire safety was below hospital targets. The practice based educators told us staff that had not completed relevant training had been booked on to courses during 2026 to improve compliance.

Records showed 98% of nursing staff and 91% of medical staff across the urgent and emergency care services had completed relevant tier 1 learning disability and autism awareness online training. The service reported the trust was working alongside system partners to develop tier 2 training to meet the standards within The Oliver McGowan Code of Practice. The code of practice standards include a requirement for staff to participate in live and interactive training that is co-produced and co-delivered by people with a learning disability and autistic people.

The staff we spoke with told us they completed mandatory training and had regular appraisals. Staff told us managers supported them to complete their mandatory training during work hours and they could claim back time if they had completed any training outside of work hours.

Staff received a full induction before they started work and their competency was assessed before working unsupervised. Most nursing and support staff (90%) and medical staff (91%) across the urgent and emergency services had completed their annual appraisals within the past 12 months.

Staff received competency-based training and development as part of their continual professional development. Competency-based training was provided by trained individuals (such as practice based educators and senior medical and nursing staff). Training files were maintained by the practice based educators. Records showed most staff had completed competency-based training that was relevant to their role. Most staff we spoke with were positive about on-the-job learning and development opportunities and felt confident to do their role.

The service reported there were no outstanding concerns relating to General Medical Council (GMC) or Nursing and Midwifery Council (NMC) revalidations for staff across the urgent and emergency care services.

We scored the service as 2. The evidence showed some shortfalls. The service assessed and managed the risk of infection. However, staff did not always follow guidance around hand hygiene and use of personal protective equipment. Routine audits showed poor staff compliance in some infection control standards.

There was a mandatory requirement for all staff, patients and visitors to wear face masks whilst in the emergency department (ED) during the week of our inspection, in order to reduce the spread of seasonal ailments, such as flu and colds. Disposable masks were readily available. Most staff, patients and visitors wore face masks whilst in the department and staff encouraged those who did not. However, we saw a number of occasions where staff members had not worn face masks whilst in the department.

The department had a risk assessment in place for the use of face masks. We found this did not make reference to the face mask requirements during the week of our inspection. We raised this with senior staff, who told us this would be updated.

There were enough hand wash sinks and hand gels. Whilst we observed most staff following hand hygiene and 'bare below the elbow' guidance, we also saw some instances where staff did not routinely wash their hands or follow hand hygiene guidelines. We saw most staff used personal protective equipment (PPE), such as gloves and aprons, while delivering care. Managers told us where poor hand hygiene compliance was identified, this was discussed with individual staff members to improve compliance.

Routine infection control and hand hygiene audits were carried out to check compliance against infection prevention and control policies and guidelines. Audit results showed poor staff compliance against some infection control standards.

Environmental infection control audits undertaken during August 2025 and November 2025 showed the UTC achieved 91% compliance and met the hospital’s 90% compliance target. However, the SDEC (88%) and ED (82%) showed partial compliance and failed to meet the hospital’s 90% compliance target. Action plans were in place to improve shortfalls identified in the audit and follow up audits were planned to check improvements had been made.

Staff carried out monthly IPC practice audits, which included 5 elements relating to hand hygiene facilities, hand hygiene observations, PPE, cannula care and catheter care. Audit results between July 2025 and December 2025 showed poor compliance and the urgent and emergency care services consistently failed to achieve the 90% compliance standard during this period.

All the areas we inspected were visibly clean and had suitable furnishings which were clean and well-maintained. Cleaning schedules and daily checklists were in place and up to date, and there were clearly defined roles and responsibilities for cleaning the environment and cleaning and decontaminating equipment. Children’s toys and play equipment was suitably cleaned and decontaminated as part of routine cleaning schedules.

Patients identified with an infection were isolated in individual cubicles or moved to a side room. We saw isolation cubicles had appropriate signage to make staff, visitors and service users aware of any potential risks.

Patients and relatives told us the premises and equipment were visibly clean and tidy and they did not have any concerns relating to the cleanliness of the environment and equipment.

Staff understood the processes for managing risks related to the infections. They were able to describe how they cleaned and decontaminated equipment. They told us they could seek advice and support from the hospital-wide infection control team when needed.

Infection prevention and control (IPC) policies were available to provide guidance to staff. Most staff had completed mandatory IPC training and overall training compliance across was better than the hospital’s 90% target. Most staff had also completed mandatory aseptic non-touch technique training. However, training compliance for medical staff (76%), adult ED nursing staff (86%) and paediatric nursing staff (71%) was below the hospital’s 90% target.

There had been no healthcare-associated infections or outbreaks reported by the urgent and emergency care services during the 12 months prior to our inspection.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

There was a clinical pharmacy service available within the department on weekdays. The pharmacy team supported medicines history taking, discharge prescriptions and counselling for patients going home with medicines from the emergency department. There was a clear process for staff to obtain medicines and advice outside of these hours. Audits within the department showed that the pharmacy team completed prescriptions in an average of 18 minutes in 2025. In November and December 2025 100% of patients had their medicines reconciled within 24 hours of having a decision to admit recorded.

Although staff told us there was a process in place to identify patients on arrival to the department who were taking critical medicines (medicines that should not be missed or delayed), this was a paper-based process that relied on communication between ED staff and the pharmacy team when they were available in the department. This meant that there was a risk that patients on time critical medicines would not have this handed over and could miss doses of medicines. The service was reporting into a national Royal College of Emergency Medicine (RCEM) audit on time critical medicines and the report for 2025 showed they were meeting all the national averages.

The service was not meeting the recommendations in the Royal College of Emergency Medicine standards regarding pharmacy staffing and pharmacy services in the emergency department.

Staff in the paediatric urgent treatment area had amended clinical pathways to support medicines compliance. For example, they had changed a steroid medication used so that patients would only need to receive one dose in the department rather than a course they would need to complete once they were discharged.

The department used multiple electronic systems and paper records to document a person’s medicines and related care notes. We found this meant that information was stored in multiple places and for 1 patient this meant that their allergy status had not been correctly recorded across all required paperwork. This put them at risk of receiving a medicine they were allergic too.

Although staff documented the time of administration of medicines when in the department, for 1 patient we found that clinicians had not documented the time a pathway was started for a person with a diagnosis of sepsis, and sepsis paperwork available was not always completed. We could not be assured that this patient had received their antibiotics within the required timeframe.

Medicines were stored securely. Medicines that have a shortened expiry once opened did not always have the open date recorded so it was not always clear if these medicines had expired. Devices used to administer medicines for single patient use were not always labelled as such and there was a risk these could be used for multiple patients.

Staff completed temperature monitoring of areas used for storage of medicines however we found that in some areas temperatures were not monitored daily as per the trusts policy.

Staff completed medicines training within the department; however not all staff had completed required competencies, in the ED the rate of completion was 86.8% and in the paediatric department it was 57%.

We found some shortfalls in the way security codes for digital locks on medicines cabinets were managed. We raised this with staff during the inspection and we received assurance that actions had been taken to address this.