Basingstoke and North Hampshire 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

This means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question as requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe, which put people at an increased risk of harm.

Overall, patient safety in the service was compromised by shortfalls in the management of risk, environmental safety, and infection prevention and control. There was ongoing poor compliance with essential training (including resuscitation and life support) which created gaps in clinical competence. The service also demonstrated a gap in its learning culture, failing to effectively act on prior safety events. This was evidenced by the unsafe physical environment for vulnerable patients, particularly those in mental health crisis. Some of these shortfalls had been identified in the previous inspection (April 2020), such as mandatory training compliance and the unsuitability of the mental health environment. The sustained nature of these problems indicated a lack of effective improvement over time.

The service was in breach of regulation 12 under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Safe care and treatment.

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.

Description: We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

We scored the service as 2. The evidence showed some shortfalls. The service did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

The Emergency Department’s (ED) governance team demonstrated a reactive learning culture, and identified shortfalls did not always encourage change. While staff understood their roles and shared learning, it did not always result in a proactive management of risk. This suggested a gap in learning culture and an ineffective response to prior safety incidents. For example, we identified incidents had occurred prior to our inspection and the risks had not been reduced. In one incident, a patient used a drug giving set and wrapped it around their neck as a ligature. During our inspection, we observed doors to assessment rooms in the fit to sit area remained open, granting easy access to clinical equipment such as needles and tourniquets that could be used for self-harm. Although staff told us these doors would be closed to prevent public access, there was no documented risk assessment or oversight mechanism to ensure this happened consistently. The lack of change identified that the service had not acted effectively on previous incidents to reduce risks to patients. This meant vulnerable patients attending the service faced an ongoing risk of harm.

Despite learning being reactive and inconsistent, we did find some examples where learning had been effective. For example, the ED experienced 3 incidents between December 2024 and May 2025 where patient volume and staff shortages led to patients being cared for in the corridor. The introduction of earlier assessment by senior doctors meant quicker treatment decisions could be made, resulting in faster access to care. This in turn improved patient flow through the department and meant patients had not been cared for in the corridor since the 3 noted incidents.

Staff knew how to report incidents, including near misses, and their significance. For example, one staff member discussed how they completed an incident report as they were unable to locate a bladder scanner. A logbook was kept tracking its whereabouts, but this had not been kept up to date. As a result, all staff were re-briefed on the need to keep the logbook current, to ensure it was always accessible.

Staff told us debriefs were held after serious events. We observed this during our inspection where staff received a debrief after a cardiac arrest and told us this helped them process events and identify any learning points. Managers provided support to staff after serious incidents.

The trust transitioned to NHS England’s Patient Safety Incident Response Framework (PSIRF) in 2024. This focused the service on ensuring learning from incidents and providing compassionate and meaningful engagement with all those affected. Managers investigated incidents, and patients and their families were involved in these investigations.

Staff understood the duty of candour. They were open and transparent and gave patients and families an explanation of when things went wrong. We reviewed their last 3 Patient Safety Incident Investigation reports and found duty of candour was correctly implemented. This meant the service were following their legal obligation to be open and transparent. The ED reviewed other incidents through its monthly Mortality and Morbidity reviews. These reviews focused on identifying areas for improvement by analysing patient deaths and significant complications.

Description: We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service established effective pathways to manage patient flow, ensuring safety during transitions between acute care stages within the Emergency Department (ED). The ED implemented a ‘teams escalation chart’ to structure and improve handover communication between the Rapid Assessment and Treatment (RAT) area, and other areas in the department.

Patients were streamlined and handed over to various services based on acuity, including the Same Day Emergency Care (SDEC) Unit and the Urgent Treatment Centre (UTC). The SDEC was correctly used for its intended purpose of admission avoidance, and maintained equitable access, rather than being used as an overflow area.

The service provided specific pathways for frail and complex patients by utilising same-day services and community support. The Frailty SDEC Unit provided an assessment by a specialist Multidisciplinary Team (MDT) for patients aged 65 or older with complex conditions (for example, recurrent falls).

These pathways helped to ensure high-risk, complex, and frail patients received holistic, and prompt care without being exposed to the risks of a long hospital stay. The exclusion criteria for the Frailty SDEC ensured that patients who required immediate medical care were not sent via this route.

The ED implemented a Standard Operating Procedure (SOP) to help manage ambulance handover delays, aiming to maintain safety while patients waited. The Emergency Physician in Charge (EPIC) took overall clinical responsibility for all patients upon arrival, as well as those still in ambulances. Ambulance and ED staff jointly monitored and escalated any patient deterioration. There were also specialised hospital teams for stroke and cardiac patients who would provide treatment guidance for ambulance staff while they were still in transit. This level of communication allowed crews to bypass the ED and hand the patient directly to the relevant inpatient specialty.

The service had established clinical pathways for common conditions, guiding staff in delivering timely care. These pathways were highlighted using symbols on electronic patient records. For example, if a patient’s record was marked with a red flag, this meant staff needed to consider moving that patient to the resuscitation room. For chest pain, time critical interventions included an electrocardiogram (ECG) within 15 minutes. We saw this in practice in the RAT area and a patient had chest pain. Staff immediately conducted initial observations and an ECG. Staff told us they would always ask the EPIC to review the ECG results to further determine next steps and ensure an immediate decision was made. This evidenced the working application of this pathway.

The service recognised the risks associated with delays in transferring patients presenting with mental health conditions, and invested in multi-agency meetings. It has been identified that external mental health service capacity remained a challenge. Leaders made it a priority to work with partners to support the transfer of patients experiencing mental health crisis to specialist services as quickly as possible. Multiple daily meetings were held with mental health partners to manage transfers and maintain situational awareness (tracking how many patients were waiting and why). Staff continued to escalate and advocate for this patient cohort, however, the lack of external mental health services meant these patients faced long waiting times.

Description: We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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.

Data we received showed a compliance rate of 89% for nursing staff in Safeguarding Adults Level 2, and 85.7% in Safeguarding Children Level 3. For the medical team, compliance was 88% for Safeguarding Adults Level 2, and 83.6% for Safeguarding Children Level 3 but it dropped to 74.3% for Safeguarding Children Level 2. Leaders told us the hospital’s safeguarding team would be conducting additional training sessions for Emergency Department (ED) staff to assist with increasing compliance.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did so when appropriate. Staff knew where to locate safeguarding policies for both adults and children, and these policies were based on relevant legislation and best practice guidance.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. For example, they knew to notify the safeguarding team if parents wanted to take a child home against medical advice.

We saw additional markers were added to the electronic patient record to better identify patients with previous safeguarding concerns. This meant healthcare professionals could immediately consider a patient’s level of vulnerability when making clinical decisions, assessing risk, and planning care.

The department provided information on domestic abuse and carer support. Posters gave a definition of domestic abuse, including verbal and emotional forms, and directed individuals to speak with staff or an independent advocate.

The Child and Adolescent Mental Health Services (CAMHS) team was available onsite during the day, and on-call for out-of-hour support. Staff understood their responsibility to protect children and young people, and they worked effectively with outside agencies like the police and local authorities to ensure their safety. The ED had a paediatric safeguarding link nurse to provide support and advice.

The trust’s Restrictive Practices Policy outlined how to use and minimise restrictive practices, ensuring any use of restraint was lawful, proportionate, and the least restrictive option available. This was guided by the Mental Health Act (1983) and the Mental Capacity Act (2005). Staff reported security personnel were available to intervene when a patient’s behaviour posed a threat to themselves or others. Staff feedback regarding the availability of security was mixed, although all who commented found them to be supportive. The trust recognised the increased incidents of violence and aggression in the department, and in November 2023, employed an additional security officer for the specific purpose of providing support for the ED.

We reviewed the last 3 incidents involving restraint and found the team, including security, responded appropriately and the use of force was justified and aligned with policy. This meant staff worked together effectively, which helped to mitigate risks to patients, staff, and others within the department.

Description: We work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service could not demonstrate that patient observations to assess acute illness and identify risk of deterioration were always recorded, this was evidenced in trust audit data. Physical observations were used to recognise and respond to patient deterioration. The service used the National Early Warning Score (NEWS2) for adults and the Paediatric Early Warning Score (PEWS) for children, aligning with national guidance. The NEWS2 score is based on 6 clinical measurements such as blood pressure, pulse, and temperature, which triggers specific actions. Although we saw this process being conducted during our inspection, audit results identified shortfalls in staff documenting NEWS2 and PEWS scores for adults and children. Audit results from August 2024 to July 2025 submitted by the trust on their deteriorating patient audit shows compliance ranging from 77% to 30% recorded in July 2025. Since this audit data was provided, the trust have identified issues with the validity of the audit tool and have plans to rectify this.

A thematic review of 75 incidents flagged as ‘deteriorating patients’ recorded as no harm or low harm highlighted negative outcomes for patients, including delays in escalating concerns to doctors, and missed opportunities to start essential treatments like intravenous fluids and medicines. This posed a risk staff were working without the full picture of a patient’s health. For example, if vital signs are not consistently recorded, staff could not see important trends over time. This made it difficult to tell if a change was normal for a specific patient or a sign of deterioration. This created an ongoing patient safety risk where clinical deterioration may not always be recognised as soon as possible for adults and children. While leaders responded by reminding staff of the importance of documentation at daily handovers and conducting spot checks, these measures did not demonstrate or resolve the ongoing lack of compliance. This consistent shortfall left the service unable to evidence that all patients were monitored as per policy, placing them at an increased risk of harm.

During our inspection, we identified that patients were unable to access standard beds in the major’s area. We observed all patients accommodated on trolleys rather than beds. Staff told us the physical layout and space constraints compromised staff’s ability to move patients onto beds. However, staff told us the trolleys could provide pressure relieving care which helped to mitigate the risk of skin deterioration. A review of the department’s incident log from April to June 2025 found no reports of hospital-acquired pressure damage. Staff proactively recorded a significant number of patients attending the department with pre-existing pressure damage, to support appropriate early specialist referrals. Staff completed incident reports for these wounds and referred patients to tissue viability nurses. Staff told us patients were typically moved onto a bed after being admitted to the Acute Assessment Unit (AAU). This meant staff were acting on identified risk to keep patients safe.

Staff told us some people could experience waits in an ambulance. The number of ambulance handover delays over 60 minutes at the service showed fluctuations but have been consistently lower than regional and national rates from June 2024 to October 2024. In recent months, there had been an increase in longer handovers, especially between 30 and 60 minutes. To ensure safety, the service had a policy to guide staff on caring for patients remaining on an ambulance. The policy, aligned with NHS guidance, stated patients became the hospital’s clinical responsibility as soon as they arrived, even if they remained on the ambulance. The Emergency Physician in Charge (EPIC) reviewed patients in the ambulance when required and could direct paramedics to begin initial treatments. Staff told us they worked with the ambulance service to offload patients based on clinical priority and arrival time. Ambulance staff we spoke with reported a good working relationship with the ED staff.

The service demonstrated a timely response to the start of treatment for time-critical conditions. For example, the ED used a screening tool for sepsis, and all staff had received training on its use. A process was in place for treating patients with sepsis and strokes while they were still in the ambulance (pre-hospital). Sepsis audit compliance for the 1-hour intravenous antibiotic window was 100% from June 2024 to June 2025. While we did not observe any active sepsis cases during our inspection, all staff demonstrated a good understanding of sepsis management.

The service had established a multi-step assessment system to ensure patients were quickly seen and directed to the appropriate care stream. For example, initial assessment (streaming) for self-presenting patients was performed by a trained ED nurse to quickly assess and direct patients. This process included their presenting complaint, an initial set of observations, and the patient’s past medical history. National guidance informed this should occur within 15 minutes of arrival, and staff told us this was adhered to. We saw self-presenting patients being seen soon after their arrival and our review of records onsite identified this process was effective where all patients had received their 15-minute initial assessments. Similarly, we saw staff in the Rapid Assessment and Treatment (RAT) area (for patients arriving by ambulance) conducting observations, carrying out blood tests, and administering intravenous fluids. This process meant patients could be prioritised and streamlined to the correct pathway for their needs and supported the early recognition of unwell patients.

The service also monitored patients in the waiting area after their initial assessment had been conducted. For example, patients who scored lower on the NEWS2 scale alongside clinical judgement (as identified at the initial assessment) were sent to a large waiting area. This area was staffed by a nurse using a workstation on wheels who then performed the secondary assessment (more detailed than the first). We saw this in practice, and this also meant there was a designated person to have oversight of the patients in this area. Patients told us they reported feeling safe and able to approach staff if they felt their health was deteriorating, with confidence staff would respond to their concerns. Leaders recognised waiting in a general area carried an inherent risk of patient deterioration that could go unnoticed. This mitigation helped to reduce this risk by ensuring ongoing clinical presence.

Paediatric patients followed a similar triage process and underwent an initial and secondary nursing assessment which included a set of vital signs, limb observations and a nurse safeguarding check. The first set of vital signs and the secondary assessment were documented on the computer system, making it visible for the EPIC and the NIC.

Staff used an ED patient safety checklist outlining the clinical tasks and risk assessments needed for each patient. The service audited staff compliance with the checklist in July 2025, and found improvements were needed, particularly for patients with long stays and the recording of food and fluid intake. Leaders told us they introduced an action plan to provide training on the checklist.

Staff told us the Mental Health Liaison Team responded to urgent requests within 1 hour. This helped to ensure patients experiencing acute mental health crisis received timely assessments. Staff could also access documentation from the team to inform their decision making. This included patient histories, risk assessments, and management plans. For example, we reviewed a management plan for a patient experiencing mental health concerns, and this described the actions staff would need to take if the patient tried to abscond from the department. This meant staff had a clear pathway to follow to manage this risk. For patients who frequently attended the department or had complex needs, the service used individualised care plans linked to their record. These tags served as a reference guide helping to ensure personalised care strategies, de-escalation techniques, and established treatment pathways were consistently applied by any member of the clinical team involved in the patient’s care. This meant risks were communicated well and staff had access to important patient information to help keep vulnerable patients safe.

Description: We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

We scored the service as 1. The evidence showed significant shortfalls. The service did not detect and control potential risks in the care environment.

The Emergency Department (ED) did not provide a safe and appropriately secure space for adult patients presenting with mental health issues. At the time of the inspection, there was no designated ligature-free space for patients experiencing mental health problems, resulting in them being placed in the general ED. We identified multiple hazards in the environment, which included exposed metal pipework in cubicles (due to ongoing renovation works), accessible oxygen tubing that presented a ligature risk, and an unlocked storage room containing sharps like scalpels and needles, with no locking mechanism. In the fit to sit area, there were multiple assessment rooms with doors left open. Inside these rooms were trolleys containing needles, tourniquets, and other clinical equipment that could be used for dangerous purposes. Staff told us if a patient experiencing a mental health condition deemed to be at high-risk, then these items would always be removed. However, this could not be evidenced and incident reports provided clarity on this risk where patients had accessed equipment and used this to harm themselves.

The lack of a secure environment compromised the privacy and dignity of patients in mental health crisis, combined with the presence of readily accessible harmful items. This created an avoidable risk of self-harm, or harm to others. Leaders acknowledged the high-risk nature of the environment and have since made changes. A safe space for adults experiencing mental health distress became operational on 11 September 2025, and the Mental Health Liaison Team was to be based in the department overnight from 15 October 2025. Further actions included locking all unsecured storage rooms and issuing a reminder to staff to secure clinical equipment. Leaders told us they would implement regular matron walkarounds and spot checks of the environment. However, further evidence was needed to show how these changes had become a sustainable part of the department’s daily operations.

Despite the environmental challenges, the department maintained a good standard for the management and readiness of emergency equipment. The service regularly audited its resuscitation trolleys, which were conducted every 6 months by the resuscitation team across all areas in the ED. Staff completed daily checks that verified all equipment, including defibrillators and suction machines, were working, and medical supplies were present. This was evidenced by our review of the checklists, which confirmed staff had consistently signed off, and necessary restocking was completed. Audits in February and March 2025 confirmed all resuscitation trolleys were in full working order. This meant staff had the necessary tools and resources to respond quickly to life-threatening emergencies. And equipment readiness minimised any risk of clinical delay.

Despite significant pressures on demand and capacity, the trust was committed to ensuring patients were not cared for in corridors and had a zero tolerance to corridor care. Where this was breached, an incident would be reported through the trust’s governance processes. Since December 2024, there had been 3 recorded incidents of corridor care. At the time of inspection, no patients were being cared for in corridors.

Description: We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

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. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

The service did not meet their 90% compliance target completion rate for some statutory and mandatory training. Across medical and Healthcare Assistant (HCA) staff, several modules fell short: the medical workforce sat below target for Resuscitation (78.7%), Fire Safety (78.7%), Infection Control Patient Facing (78.7%), Safeguarding Children Level 2 (74.3%), and Data Security and Protection (79.6%). Similarly, HCA’s had a compliance of 68.6% (Resuscitation), and 78.4% for Moving and Handling. This meant there were identifiable gaps in clinical competence and organisational safety measures, creating a risk for patient care.

Due to the nature of the environment, we also reviewed compliance data for life support training across different staff groups and found significant shortfalls (as of July 2025). For example, Basic Life Support (BLS) compliance for the medical team was 54.5%; Intermediate Life Support (ILS) compliance was 73% for nursing staff (required for all clinical Bands 5 to 8); Paediatric Intermediate Life Support (PILS) was 64.4% (required for all clinical staff Band 5 to 8); Advanced Life Support (ALS) was 27.2% (required for Band 6 and above), and European Paediatric Advanced Life Support (EPALS) was 17% (required for Paediatric Nurses and Band 6 upwards).

The service’s implementation of an action plan to address this gap was noted, and a positive step forward in addressing staff compliance. For Immediate Life Support, the service introduced short, frequent training sessions. Mitigation for Paediatric Life Support focused on building internal capacity and attendance management where progress had been made with one additional instructor. To address Advanced Life Support compliance, the department had secured funding and allocation for 7 places by December 2025. The team was working with ALS instructors to provide supplementary training and simulation sessions, bridging gaps in official course attendance and enhancing in-house clinical knowledge. The European Paediatric Advanced Life Support mitigation plan was to secure funding for the 20 places required to reach 100% compliance. However, the overall action plan did not demonstrate a timely response in mitigating the immediate risk. There was no documented information on how existing gaps in staff compliance would be addressed in the short term. This meant staff did not have the appropriate skills and up to date knowledge for both adults and children requiring advanced resuscitation skills.

The Adult Emergency Department (ED) faced shortfalls with their Healthcare Assistant (HCA) workforce. Data from February to July 2025 identified an ongoing staffing deficit whereby the department was understaffed by more than 10% for nearly 30% of the week. The service was short-staffed 100% of the time on Sundays between 9am and 10am from February to July 2025, falling below 70% of the required staff during this hour. However, in times of increased demand there was the ability to reassign those on supernumerary days to support the department and utilise staff from other clinical areas. If the department had an HCA deficit, there was usually an increase in Registered Nurses to provide additional support.

The service responded to staffing concerns by implementing an improvement plan. Previously, the HCA staffing template was met on only 8 out of 66 days (April to June 2025). But following a focused staffing review, the RAT area achieved 100% compliance with planned versus actual staffing levels between 3 June to 30 June 2025. This helped to reduce clinical risk in a high-flow area; however, we were unable to assess if this led to sustained improvements.

The department used temporary workers from bank and agency to bridge staffing gaps. Their average fill rates for nurses were consistently above their template 100% of the time from January to June 2025. The average fill rate represents the percentage of planned shifts that were covered by staff. However, the average HCA fill rate remained consistently below planned numbers for both day and night shifts across the same 6-month period. This gap was not significant (with the lowest fill rate at 92.28% in February), but it identified a persistent shortfall and necessitated a reliance on temporary staff. This meant HCA bank staff worked a total of 108.57 hours between January and June 2025 to mitigate this shortfall.

The service was aware of the risk of insufficient nursing and HCA staffing levels, and we saw this on their departmental risk register. To address these shortfalls, they recruited and onboarded new staff, including Band 6 nurses and used secondments from other wards. They conducted regular safer staffing reviews and weekly roster checks.

During our inspection, senior ED staff, including the Nurse in Charge (NIC) responsible for shift oversight, expressed confidence they were meeting their established staffing numbers most of the time. However, staff told us the existing staffing template for both nurses and HCAs did not always meet patient demand, as patient needs sometimes exceeded their ability to deliver safe care. We were told for example, patients experiencing mental health conditions who required continuous one-to-one observation could not always receive this because the template failed to account for additional staff.

In response, the service had developed their own in-house mental health support team which included Registered Mental Health Nurses (RMNs) and Enhanced Care Workers. If a patient had been identified as high risk (self-harm or absconding), they were recommended for one-to-one care and supported by department staff. During our inspection, we identified 3 patients receiving one to one care from RMNs.

The service identified their Enhanced Care and Observation in Adults Policy which outlined patients assessed as potentially at risk of harm, should receive intermittent observations every 10 to 20 minutes. Staff told us this did not always happen. An incident log review identified staff had reported a number of incidents relating to their inability to ensure this always happened. This meant actual practice did not always meet the required safety standard and put vulnerable patients at an increased risk of harm.

The ED had implemented a system for assessing and escalating patient acuity, which acknowledged that staffing numbers alone were not sufficient in guaranteeing patient safety. The NIC was required to complete an acuity-based assessment on every shift. This was escalated through formal channels, including daily meetings and safety huddles. This meant staffing shortfalls were identified and brought to the attention of senior leadership. However, leaders could not always provide additional staff when needed.

To determine the effectiveness of the medical staffing model, we reviewed the numbers of consultants per shift against the number of patient attendances from April to June 2025. The data identified that the total average of daily consultants ranged from 3.5 to 3.9 across the 3 months. The late on call (additional medical staffing support) resource was used once in April. The service tried to mitigate any medical staffing issues by focusing on recruitment and inter-departmental support. They recruited for various roles, including a trust grade acute physician and used long-term locum consultants to provide stability and fill vacancies. Additionally, they maintained coverage for their Same Day Emergency Care (SDEC) service by using locum staff to ensure it operates 7 days a week.

In the Paediatric Emergency Department (PED), the service demonstrated the ability to provide adequate staffing. The PED was described by staff as “extremely well organised”, maintaining safe staffing levels by always including at least one registered paediatric nurse, supplemented by adult nurses with paediatric training.

The ED maintained a safety net for paediatric emergencies. A documented Standard Operating Procedure (SOP) described a timely and evidence-based response to paediatric cardiac arrests. This required staff to identify a designated Advanced Paediatric Life Support (APLS) provider on every shift, ensuring a qualified individual was always available to lead an arrest, particularly when ED staff lacked APLS certification. Senior ED staff told us this always happened, and they always had a designated person identified on every shift. This meant a child experiencing a life-threatening emergency would receive immediate care.

Description: We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection.

The Emergency Department (ED) did not always follow safe Infection Prevention and Control (IPC) practices. The trust had an IPC policy which included guidelines for staff to follow, such as washing hands before and after patient care episodes and the use of Personal Protective Equipment (PPE). Over a 30-minute observation period in the Rapid Assessment and Treatment (RAT) area, we identified 3 staff members did not wash their hands between patients, and staff not cleaning clinical equipment in between patient uses.

We saw not all equipment was clean, including an electrocardiogram (ECG) machine and an observation machine with sticky residue and dust. We also found a box containing filled urine samples sitting on top of the reception desk in the fit to sit area. There was no process to highlight equipment that had been cleaned and ready to use. This meant staff could not easily identify what equipment had been cleaned. We noted other issues that could prevent effective cleaning, such as peeling paint on the waiting area walls, and a taped-over section of flooring near the resuscitation room. This posed a risk of cross contamination for patients, and the inability to adequately clean clinical areas.

A review of the service’s hand hygiene audit data showed a mixed level of compliance. For example, no data had been submitted for February and March 2025. Staff complied with good hand hygiene practices 60% of the time in April, 70% of the time in May, and 100% of the time in June and July 2025. Although this showed an improving picture, it did not represent what we saw, and missing audit data meant leaders could not ensure staff consistently followed policy.

We observed the only available sink in the RAT area was in a patient’s bed space. This meant both staff and other patients had to enter the bed space to wash their hands. This impacted on the privacy and dignity of the patient residing there. However, there were 4 alcohol gel stations within the RAT area as an alternative IPC precaution and visible hand hygiene guides.

Staff training for IPC received more than 78.7% compliance for all staff groups, which did not meet the trust’s target compliance of 90%. We were told patients admitted with a known infection risk would be isolated in a single cubicle, and this risk was communicated to others using posters on cubicle doors. This helped to minimise the risk of spreading infection.

We observed domestic staff ensured floors remained clean despite heavy foot traffic. The service used easy-clean, non-porous surfaces for flooring and chairs, disposed of clinical waste properly using different coloured bins, and PPE was fully stocked and readily accessible. This meant staff had enough resources to follow IPC practices.

The senior team recognised the need for improvement through hand hygiene audits, and the IPC lead detailed immediate actions, including the introduction of a commode cleaning checklist, and for the implementation of ‘I am clean’ stickers. However, we did not see these improvements in practice on our inspection, and these concerns were not detailed on the department’s risk register.

Following our inspection, weekly spot-checks were initiated by senior teams (ED, IPC, and Patient Safety), additional posters detailing the ‘5 moments of hand hygiene’ were placed at all sinks, and a temporary second sink was installed in the RAT area. This reflected the senior team’s responsiveness in addressing these shortfalls, but implied further work needed to be done to ensure consistent and embedded change.

Description: We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

A clinical pharmacist was employed in the Emergency Department (ED) 2.5 days a week, supported by a pharmacy technician who performed medicines reconciliation. We found the management of controlled drugs (CD’s) to be secure. These were kept in 5 locations across the department. The CD’s were separated from other medicines in a locked cupboard, and a register was used for strict monitoring. Our review of the controlled drug register in the resuscitation room confirmed all CD’s were accounted for, with clear documentation and a balance sheet.

We found FP10 prescription forms were stored in a safe, and each form was logged and accounted for when used. An FP10 prescription is used when a patient is being discharged or is receiving care that requires them to obtain medication from a community pharmacy. This prevented misuse of these forms.

The service conducted quarterly audits for medicines management, and a review of the April 2025 audit revealed some shortfalls. To correct these issues, the department developed and implemented an action plan. This plan mandated quarterly changes to access codes, the creation of an up-to-date staff name list for CD orders, staff training on resetting fridge temperatures, and accurate documentation of liquid medicine opening dates.

During our inspection, we observed compliance across these areas. Controlled drug orders were accurate, fridge temperature logs were completed, and staff reported and acted upon any fridge temperatures outside the acceptable range. This evidenced how the action plan maintained safer medicine management.

Staff gave some medicines using Patient Group Directions (PGD). A PGD is a set of instructions used by healthcare professionals to administer specific medicines to a pre-defined group of patients without the need for a doctor to prescribe. This meant staff did not have to wait for a prescription from a doctor to administer specific medicines (for example, paracetamol for pain relief).

Feedback from staff indicated it was sometimes difficult to gain a full medicine history during the patient streaming process without access to their primary care records. However, they also stated most patients could accurately report their own medicines.

The department was working to implement an electronic medicine prescription to ensure electronic medicine charts were used alongside electronic clinical notes to reduce the risk of errors occurring. This was identified as a risk on the department's risk register.

The service had a team that monitored antibiotic use to ensure proper prescribing. This team reviewed prescribing data and gave feedback to staff during weekly ward rounds, multidisciplinary team meetings, and incident investigations. This helped to ensure appropriate antibiotic use and served as a continuous learning opportunity for staff. Medicine errors were logged online and reported to relevant people for investigation and learning.