Cumberland Infirmary

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 requires improvement. At this assessment the rating has changed to inadequate.

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

This meant people were not safe and were at risk of avoidable harm.

We identified significant and repeated risks. The service did not always have a proactive and positive safety culture. Incident reporting, investigation and learning systems were not implemented effectively. Infection prevention and control systems were not always assessed, embedded or followed. The service did not always monitor or manage people’s safety, particularly patients waiting in the waiting room, patients at risk of deterioration and patients with mental health needs. Staffing levels were not sufficient to provide consistently safe care. Several concerns identified during our assessment in February 2026 remained unresolved or only partly addressed when we returned in March 2026, which increased the risk of avoidable harm to people using the service.

The service was in breach of the legal regulations relating to safe care and treatment, premises and equipment, staffing and good governance. These breaches were supported by the cumulative impact of unsafe systems, insufficient staffing, environmental risks and weak governance arrangements, which meant people were exposed to avoidable risks that were not always identified, escalated or reduced promptly.

We have not awarded this service a score for Safe.

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

The service did not have a proactive and positive culture of safety based on openness and honesty. Staff did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The service had systems in place for staff to report and raise concerns, and staff were able to describe examples of incidents involving staffing pressures and delays in care. However, the service could not demonstrate an effective learning culture. Significant backlogs within the incident management system meant that incidents were not always reviewed, investigated or acted upon in a timely way. At the time of assessment, 115 incidents were awaiting manager review, with the majority having been open for up to 60 days. This limited assurance that learning was identified, shared and used to prevent recurrence.

There had been 1072 incidents reported in the Learning from Patient Safety Events (LPSE) system from August 2025 to January 2026. Staff reported that the introduction of the Patient Safety Incident Response Framework (PSIRF) had begun to support a more open culture and move the service away from blame. There were a wide range of incidents reported including staffing shortfalls, patients presenting with pressure ulcers from the community, medication errors and falls.

While leaders described several mechanisms for sharing learning, including governance meetings, newsletters and handovers, evidence of learning was not consistently visible or embedded. Information displayed within clinical areas was out of date, and delays in complaint handling and limitations in complaint categorisation reduced opportunities to identify themes and implement improvements.

Although incidents involving patients with mental health needs had been reported through the Learning from Patient Safety Events (LFPSE) system, the service was unable to demonstrate that previous incidents of self-harm had been fully investigated or that learning had been embedded to reduce future risk. Where investigations had taken place, action plans were not consistently developed, lacked clear accountability, and did not always include timescales for completion. In some cases, reviews did not fully consider the potential impact of incidents, including psychological harm.

The Duty of Candour (DoC) requires registered providers to act in an open and transparent way with people receiving care or treatment. We saw evidence that DoC processes had been followed after investigations into treatment.

Overall, while there were positive signs of cultural improvement and a willingness to learn, the service was not yet able to demonstrate that learning from incidents, complaints and investigations was consistently translated into meaningful improvement or used effectively to prevent avoidable harm.

The service did not work well with people and health system partners to establish and maintain safe systems of care. Staff did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

The triage model designed to direct patients to the most appropriate areas of care was not currently effective. Opportunities to stream patients to alternative services were limited. This meant there were more patients in Emergency Department than there was capacity to manage, leading to long waiting times and impacting on patient flow.

A newly built Urgent Treatment Centre (UTC), intended to support patients with lower-acuity needs, had not yet opened due to ongoing recruitment challenges. As a result, patients who may have been better managed elsewhere continued to attend the ED, placing additional pressure on capacity, patient flow and waiting times. Leaders acknowledged the impact this was having and described an improvement programme aimed at addressing these challenges. The Same Day Emergency Care (SDEC) service provided an alternative pathway for some patients through referrals from GPs, consultants and the ED.

ED performance is monitored at the monthly ED cross site operations and governance meeting, which includes the oversight of the Triage Standing Operating Procedure (SOP) . Data reviewed for the period 26 January to 23 February 2026 showed patients waited between 9 and 25 minutes for triage. Waiting times to be seen by a clinician generally ranged from 22 to 92 minutes and met the service target of 150 minutes, although there were two occasions where average waits increased to 108 and 462 minutes. Despite this performance, staff told us there was insufficient capacity within SDEC to provide in-reach support to the main ED. During the assessment, we also observed patients remaining overnight in SDEC, further reducing available capacity and contributing to increased waits elsewhere in the department.

Throughout the assessment, staff maintained oversight of patients receiving care in clinical areas through the electronic patient management system, which enabled real-time monitoring of patient location and waiting times. However, this oversight did not extend effectively to patients waiting in the waiting room. At the time of assessment, no clinical staff had been allocated to the waiting area due to staffing pressures and operational demand. Staff reported that concerns regarding the lack of clinical oversight had been raised repeatedly without resolution and described this as a significant safety concern.

We observed several patients receiving treatment, including intravenous therapies, in the waiting room without appropriate clinical supervision. Although staff attempted to undertake observations and welfare checks, they told us this was not always possible because of workload pressures.

Following our February feedback, the trust said it had taken action to improve staffing and oversight. However, when we returned on 18 March 2026, concerns remained. There were 37 patients waiting in the waiting room. Most had waited a long time after triage, and some had waited more than three hours to see a doctor. Although most patients had been triaged, there was still no dedicated clinician overseeing the area. Reception staff could observe patients but did not have the clinical skills needed to identify when a patient's condition was worsening. Staff continued to raise concerns that risks in the waiting room were not always recognised or acted on. The trust could not show that the actions taken had not resulted in sustained improvements to patient safety.

We identified concerns regarding the monitoring of patients awaiting specialty review. Staff told us that once patients were referred to specialist teams, they were no longer actively monitored by ED clinicians. The trust was therefore unable to demonstrate effective oversight of how long patients waited for specialty input or whether reviews took place within appropriate timescales. Following the assessment the provider told us patients who are referred to specialist teams remain the clinical responsibility of the ED team until they leave the department. For patients who are lodged in the Emergency Department waiting to be admitted to a speciality bed, care would be delivered in consultation with the admitting speciality. However we did not see this operating at the time of our assessment.

The trust conducted an audit in May 2025 which reviewed 38 patients awaiting specialty assessment and demonstrated some improvement compared with January 2025. However, only 31% of specialty teams responded within the recommended 30-minute timeframe. The trust had drafted Internal Professional Standards guidance aimed at improving response times, although this had not yet been implemented at the time of the assessment.

Within the Rapid Assessment and Treatment (RAT) area, we observed patients accommodated on chairs and trolleys outside designated clinical spaces due to capacity pressures. Staff working within RAT were required to oversee these patients alongside those receiving care within the unit. Although assessments had been completed, a review of 12 patient records demonstrated that observations were not always repeated in accordance with the trust's operational policy. This created a risk that patient deterioration would not be identified and escalated promptly.

Staff undertook twice-daily handovers between shifts to communicate key safety and operational information. However, the handovers we observed did not provide leaders with clear oversight of staffing requirements or operational risks for the day ahead. Following feedback, the trust acknowledged this issue and advised that work was underway to strengthen and standardise the handover process.

Despite these challenges, there were examples of effective operational coordination across the wider hospital. Bed management meetings took place three times each day and brought together teams from across the organisation to support patient flow and discharge planning. During the meetings observed, staff worked collaboratively to address capacity pressures and facilitate movement through the hospital wherever possible.

There were also examples of effective multidisciplinary working within the department. Physiotherapists attended daily and proactively supported patients to return home safely with appropriate equipment and community support, reducing the need for admission where suitable. Information was shared effectively when patients transferred between clinical areas or were discharged, and discharge summaries were automatically sent to patients' General Practitioners to support continuity of care.

We also observed ambulance handovers during the assessment. Staff from the local ambulance service told us that delays in transferring patients to emergency department staff were uncommon, and ambulance handover data supported this.

2. The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. Staff did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately.

The provider had an up-to-date safeguarding policy that was readily accessible to staff. Staff demonstrated a good understanding of their safeguarding responsibilities, including how to recognise and report concerns, make referrals, and escalate issues appropriately. Staff had access to safeguarding advice and support from the trust’s safeguarding lead when required. However, trust data showed compliance with safeguarding adults level 3 and safeguarding children level 3 training was 59%, which was below the trust target of 85%. This presented a risk that not all staff had received the level of safeguarding training required for their role.

Staff received training in the Mental Capacity Act (MCA), with compliance rates exceeding the trust target at 86%. Staff demonstrated an understanding of the principles of the MCA and worked collaboratively with the psychiatric liaison team to ensure mental capacity assessments were completed appropriately when there were concerns about a person's ability to make decisions. This supported staff to uphold people’s rights and make decisions in their best interests where necessary. However, mental health risk assessments were not routinely carried out, which therefore meant that patients who presented with mental health needs may not be protected from further harm. We saw incidents through the LPSE data that identified where patients had been able to harm themselves whilst in the department.

Staff working within the paediatric emergency department had access to the Child Protection–Information Sharing (CP-IS) system. This enabled the timely sharing of safeguarding information with local authorities and partner NHS organisations to support the protection of vulnerable children. Staff could also access GP records through the electronic patient record system, helping to inform assessment and decision-making. We found effective processes were in place to identify children who may be at risk of abuse, neglect, or exploitation. The department maintained oversight of vulnerable children through a dedicated monitoring process and made referrals to the local authority safeguarding team where appropriate. Staff also made proactive referrals to specialist third-sector organisations to ensure children and their families received additional support.

Security staff were present within the department during daytime hours and supported clinical teams in maintaining the safety of patients, visitors, and staff. Leaders told us security staff did not undertake clinical observations but were involved in managing challenging situations, including supporting staff when restraint was necessary. Security personnel received accredited training in personal safety and conflict management. Staff told us that restraint was only considered as a last resort and that clinical staff were required to provide a clear rationale before any restrictive intervention was undertaken, helping to ensure people were protected from avoidable harm and that restrictive practices were used proportionately and appropriately.

2. 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.

Risks were not always acted on and escalated promptly. The service used multiple systems, which meant that risk process were not always streamlined and did not always involve patients.

Leaders monitored operational pressures within the department using the NHS England Operational Pressures Escalation Levels (OPEL) framework. The framework identifies escalating levels of pressure across services, with OPEL 4 representing severe operational strain. Records showed the department was operating at OPEL 4 on 16 and 17 February 2026. Despite these pressures, staff continued to assess and prioritise people according to clinical need.

Patients were seen in order of clinical priority. However, there were multiple systems used to identify and prioritise patient acuity, including the Manchester Triage System, National Early Warning Score (NEWS) assessments and manual recording on the emergency department electronic patient record system. Staff were unable to clearly explain how information from these systems was coordinated to support consistent prioritisation, and it was not evident how the effectiveness of these processes was routinely monitored or audited. As a result, it was not always clear how staff had determined and escalated individual patient needs and risk.

Patients who could walk themselves were triaged in a timely manner. Waiting times for triage were within 15 minutes and complied with Royal College of Emergency Medicine (RCEM) guidance. However, during our assessment in February 2026, we found that patients identified as being at risk of deterioration were not always reviewed promptly in line with NEWS escalation protocols.

We saw records for a patient who had a high NEWS score, indicating a high risk of clinical deterioration. One hour later the NEWS score had increased further. There was limited documentation of escalation, treatment planning or agreed care requirements. The patient’s NEWS score remained high for several hours and the next documented entry showed that the patient had sadly died. The patient’s records were incomplete, and relevant documentation had not been scanned into the record. The provider could not assure us that appropriate risk assessment, escalation, treatment and monitoring had taken place.

We found limited oversight of sepsis management. The department undertook sepsis audits quarterly, however the audits indicated consistently poor compliance in several areas such as undertaking repeated observations within the appropriate timeframe. Although 100% patients were screened for sepsis in April to December 2025, on average only 50% received treatment within the time frame. We were not assured that oversight, monitoring and treating patients at risk of sepsis was in line with best practice

The department had a pathway in place for patients presenting with mental health needs. Patients were triaged on arrival, and nursing staff were expected to complete a mental health risk assessment to identify immediate risks, including self-harm and suicidal ideation. However, these assessments were not completed consistently.

We reviewed the records of a patient who had attended following a suicide attempt and who continued to display indicators of significant risk whilst in the department. Staff documented self-harm and suicidal ideation, however, there was no evidence that a mental health risk assessment had been completed. There was no evidence that staff had considered what type of observations and supervision the patient required. The patient’s records documented that a self-harm incident was reported as a “low-harm” incident. The trust could not provide assurance that all appropriate measures had been considered to protect this patient.

We found the trust’s mental health policy available on the intranet was out of date. Our review of incident reports identified recurring themes involving patients with mental health needs, including incidents of self-harm where mental health risk assessments had not been completed consistently. This indicated opportunities for learning had not been fully embedded to reduce the likelihood of recurrence.

We raised these concerns with the provider during the February assessment. Leaders told us staff would receive additional training on mental health risk assessment processes to support consistent completion. However, during our return visit in March 2026, managers told us the only action taken had been an email reminder reinforcing the requirement to complete risk assessments. This was not sufficient to demonstrate that staff had understood, embedded or consistently applied the required process. As a result, people presenting with mental health needs remained at risk of not receiving appropriate assessment, observation or support.

The department did not use an electronic patient safety communication board to support the identification and escalation of patient risks, such as falls risks or automatic NEWS alerts. Staff had to enter risk indicators manually. Staff told us that due to operational pressures and the demands within the department, these alerts were not always added consistently. This increased the risk that important information relating to patient safety and deterioration may not always be visible to the wider multidisciplinary team.

During our follow-up assessment in March 2026, we found improvements had been made. We reviewed 5 patient records and found all patients had received appropriate risk assessments and regular clinical observations. Records included evidence of assessments of hydration and nutritional needs, sepsis screening, and intentional rounding, whereby staff will check each hour that a patient is comfortable and has their essential needs met. Documentation demonstrated that patients were being monitored and reassessed appropriately. A further review of 5 records specifically relating to sepsis showed staff had considered and documented sepsis risk at presentation. We did not identify any omissions or errors within the records reviewed.

1. The service did not always detect and control potential risks in the care environment. Staff did not make sure that equipment, facilities and technology supported the delivery of safe care.

The facilities and premises were not always appropriate for the volume of patients attending the department. There were insufficient cubicles to accommodate demand, and we observed multiple patients being cared for in temporary escalation spaces. Patients were accommodated on chairs and trolleys in areas with high levels of footfall. These environments did not always provide access to call bells and did not support patients’ privacy and dignity. This increased the risk that patients’ needs may not be recognised promptly and impacted their experience of care.

Throughout the assessment, patients experienced extended stays within the emergency department due to capacity constraints across the hospital. Patients often remained on chairs and trolleys for prolonged periods, because there were insufficient treatment spaces and inpatient beds available. Despite staff making efforts to identify appropriate beds for patients who required admission, patients at risk of deterioration remained in the department for long periods, including longer than 6 - 12 hours.

The Same Day Emergency Care (SDEC) unit contained 5 clinical cubicles and associated clinic rooms. However, only 2 treatment spaces were big enough for a hospital bed. Staff told us that patients remaining overnight as part of escalation arrangements often stayed on trolleys because appropriate beds did not fit in the remaining cubicles. Although crowding was not evident during our assessment, overnight patients reduced the department’s capacity to deliver its intended service.

The paediatric emergency department consisted of 4 assessment cubicles and 1 cot space. There were no dedicated toilet, baby changing or breastfeeding facilities within the paediatric area. Children and their carers had to leave the paediatric department and walk through the main emergency department to access these facilities. This did not support a child-friendly environment and affected privacy, dignity and convenience for patients and families. Leaders told us plans were in development to improve facilities within the paediatric area. We observed a separate waiting area that was appropriately designed and decorated to meet the needs of children.

The department had a designated room for the assessment of patients experiencing mental ill health. However, the room did not meet recommended Psychiatric Liaison Accreditation Network (PLAN) standards. We requested risk assessments, including ligature risk assessments, for areas accessed by patients presenting with mental health needs; however, these were not provided. Leaders told us they were reviewing the suitability and location of the room, but limited progress had been made by the time of our follow-up visit in March 2026. This meant the provider could not assure us that people at risk of self-harm could be cared for in an environment that reduced avoidable risk. This concern contributed to the enforcement action taken.

In February 2026, we found the resuscitation area was cluttered, and some emergency equipment was not readily accessible. We raised this concern with the trust, which informed us that a review would be undertaken to remove non-essential items from the area. During our follow-up visit in March 2026, some parts of the resuscitation area remained cluttered and access to certain emergency equipment continued to be restricted. This meant staff may not have been able to access equipment quickly in an emergency, creating a continuing risk to people who required immediate life-saving treatment.

There was not always sufficient equipment available to support safe care and treatment. Staff told us there were shortages of blood pressure monitoring equipment, intravenous pumps and privacy screens. Following our assessment feedback, the provider advised that additional monitoring equipment and drip stands had been purchased. However, in March 2026, staff reported that these items had not yet been made available within the department. This meant patients could continue to experience delays in monitoring, treatment or care delivered with appropriate privacy.

Systems to ensure emergency equipment was available and fit for use were not effective. Daily and weekly checks of resuscitation trolleys within the main emergency department were not completed in accordance with trust policy. We identified significant gaps in recorded checks over the preceding 6 months. We requested evidence of the resuscitation equipment checks within the paediatric emergency department, following our on site assessment the provider submitted data that showed that the checks had been completed with minimal gaps. The provider could not demonstrate sufficient oversight or assurance that emergency equipment was available, in date and ready for use when required. The department developed an action plan to improve compliance and strengthen oversight.

In contrast, records demonstrated that resuscitation trolleys within the Same Day Emergency Care unit were checked consistently and in line with local requirements

Score 2. The service did not always make sure there were enough qualified, skilled and experienced staff. Staff 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 have sufficient numbers of staff with the appropriate skills, training and competencies to deliver safe care.

During our assessment, nurse staffing levels within the emergency department did not meet the staffing guidance and standards set by the Royal College of Nursing (RCN), Royal College of Emergency Medicine (RCEM), and NHS England. Staffing levels had remained below planned establishment numbers for the preceding 4 months. This was particularly concerning given the level of operational pressure within the department. During our assessment, the department was regularly operating above its intended capacity, with up to 70 patients present and up to 4 patients being cared for in temporary escalation spaces.

Staffing records demonstrated ongoing vacancies and unfilled shifts. Staff told us this had been a longstanding challenge. We found that staffing levels were not routinely adjusted in response to increased patient numbers or rising patient complexity and need. The department did not undertake a formal assessment of overall patient needs to determine additional staffing requirements, despite caring for patients with increasingly complex needs and extended lengths of stay.

Sickness absence data between February 2025 and January 2026 exceeded the trust target of 4%, placing further pressure on staffing levels. A review of seven shifts across November and December 2025 identified shortages of both registered nurses and healthcare assistants on every shift reviewed. These findings were consistent with feedback from the 2025 NHS Staff Survey, which indicated many staff did not believe there were enough staff to enable them to do their jobs effectively or deliver a good standard of care.

We observed the impact of staffing shortages during our assessment. Patients being cared for in temporary escalation spaces required support to access facilities, while nursing staff were required to provide care simultaneously to the rapid assessment and treatment area and patients in temporary escalation spaces. Individual nurses were unable to maintain continuous observation of all patients within their allocated areas. This increased the risk that changes in patient condition may not be identified promptly. During our follow-up assessment in March 2026, we observed similar overcrowding and staffing pressures.

The trust did not employ dedicated mental health support workers within the emergency department, so staff were used from within the department. This reduced staffing capacity within the wider department and increased pressure on already stretched teams.

We raised our concerns regarding staffing with leaders. They explained that a recent workforce review had been completed, and a business case had been submitted to increase nursing numbers within the emergency department and strengthen workforce capacity.

The Same Day Emergency Care (SDEC) service had its own dedicated staffing team. Patients who remained in SDEC overnight were cared for by staff from the Acute Medical Unit. Leaders told us this arrangement was in place to ensure continuity of care outside standard operating hours.

The department had established an Advanced Clinical Practitioner (ACP) trainee pathway, which staff and leaders described as successful. The ACP role was well embedded within the department and contributed to clinical assessment and decision-making.

Staff with advanced skills were on each shift. For example, rotas were planned to include appropriately trained triage nurses and nurses with advanced life support skills. Staff undertaking triage duties were required to complete formal Manchester Triage training and competency assessments before undertaking the role independently. Leaders told us staff were not allocated to triage until all required competencies had been achieved.

New staff completed a structured induction programme and worked a supernumerary period before taking on full clinical responsibilities. Newly qualified nurses were supported through competency frameworks based on Royal College of Nursing Emergency Care Standards.

Appraisal compliance was below the trust's target. Trust data showed that only 65% of nursing staff had received a completed appraisal against the trust target of 90%. Managers told us operational pressures and time constraints had affected their ability to complete appraisals. Medical appraisal compliance was up to date.

The paediatric emergency department was predominantly staffed by registered children's nurses, with additional support from adult-trained nurses who had completed paediatric competencies. Dedicated paediatric medical cover was available during daytime hours. Overnight, medical support was provided by clinicians from the main emergency department. Staff told us there were occasions when response times were delayed due to competing demands across services.

Compliance with mandatory life support training was below the trust target. Adult life support training compliance was 69% and paediatric life support training compliance was 55%. The provider could not assure us that sufficient suitably trained and skilled staff would be on duty should incidents occur. We requested evidence of action plans to address the shortfall and improve compliance; this was not provided.

A consultant was physically present on site between 08:00 and 00:00 (midnight) seven days per week, after midnight cover was provided by a senior decision maker. A consultant was on call from 0:00 to 08:00 to provide senior clinical advice and support where required.

Same Day Emergency Care (SDEC) units for medical and surgical care were staffed by combination of consultants , advanced care practitioners and specialty trainees.

1. The service did not assess or manage the risk of infection. Staff did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We were not assured that effective systems and processes were consistently in place to prevent and control the risk of infection. During our assessment, the emergency department appeared visibly dusty and, in some areas, unclean. Resuscitation bays and temporary escalation spaces were cluttered with equipment and stored items, which reduced the ability to clean these areas effectively. We saw damage to walls and flooring. We raised these concerns with trust leaders following our assessment. During our follow-up assessment on 18 March 2026, we saw that the overall cleanliness of the department had improved.

Staff did not consistently adhere to infection prevention and control (IPC) requirements. In February, we observed several examples of poor hand hygiene practices and staff not following bare below the elbow principles. Leaders told us they would undertake further monitoring of IPC after our February assessment, however, we observed further instances of poor IPC and hand hygiene in March 2026. This meant people continued to be exposed to avoidable infection risks despite the trust being made aware of the concern.

Staff received infection prevention and control and hand hygiene training as part of their induction and annual mandatory training programme. Trust data showed that 92% of emergency department staff had completed IPC Level 2 training, which exceeded the trust target of 85%.

We reviewed the trust cleaning policy and identified that this was not being followed. The department used a labelling system to identify when equipment had last been cleaned. Although cleaning labels were present, we observed staff using equipment that was recorded as not having been cleaned for up to three days. The provider was unable to demonstrate how compliance with equipment cleaning requirements was monitored or how leaders assured themselves that equipment was cleaned in accordance with policy. For example, we inspected an unoccupied clinical room but were unable to determine whether cleaning had been completed, as there was no cleaning signage or documentation displayed.

The trust provided audit records of infection prevention, hand hygiene, environmental cleanliness and equipment cleaning. The policy stated these audits should be completed weekly, however, records showed audits were completed every 12 weeks rather than every week. Audit outcomes were 89% for audits between October and December 2025, and 71% between January and March 2026, below the trust compliance target of 98%.

We also found inconsistencies within audit findings. For example, hand hygiene compliance was recorded as achieving the required standard; however, the same audit documented that staff were unable to access handwashing sinks due to clutter. There was no accompanying action plan to address this issue.

The facilities and environment did not support best practice for infection prevention and control. This included a lack of ensuite facilities and the use of commodes and bedpans, with sluices for disposal not easily accessible.

We observed an isolation room where personal protective equipment (PPE) was not available outside the room and saw a cubicle being used for a patient with a potentially infectious condition without appropriate PPE being readily accessible at the point of entry. We did not observe evidence of effective cleaning between different patients in some clinical areas.

The resuscitation area consisted of an open-plan design with three treatment spaces separated by storage units. This arrangement limited the department’s ability to isolate patients requiring enhanced infection control precautions whilst receiving emergency treatment.

In contrast, we found the Paediatric Emergency Department and Same Day Emergency Care unit to be visibly clean and well maintained. Appropriate cleaning arrangements were in place within these areas. Toys available within the paediatric waiting area were cleaned regularly by the play specialist and cleaning records were completed and maintained appropriately. These arrangements helped reduce the risk of infection and promoted a safer environment for children and families.

2. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Medicines optimisation within the emergency department was supported by a senior pharmacist. There was a senior pharmacist based within the emergency department (ED) between 8.30am until 4.30pm on weekdays only. The pharmacist was rostered to work in ED routinely, with support provided remotely by pharmacy technicians. However there was no cover for annual leave or sickness. After office hours and at weekends, an on-call pharmacist was contactable for advice at any time. Pharmacy support did not meet Royal College of Emergency Medicine (RCEM) recommendations regarding pharmacy provision within emergency departments. Leaders told us business cases had been developed to increase pharmacy staffing and form part of a wider pharmacy workforce strategy.

We identified concerns regarding the storage of medicines and medical products. Intravenous (IV) fluids were stored on the floor within a clean utility room. We raised this with trust leaders, who told us storage capacity within the department was limited and that work was underway to identify additional storage solutions. This had been highlighted on the trust's medicines action plan for several years with no action taken.

In February 2026 we observed intravenous fluids stored unsecured within the resuscitation area. We raised this concern immediately with leaders. During our follow-up visit in March 2026, we found this issue had not been resolved.

We found concerns relating to the storage of medical gases. Oxygen cylinders were not always stored in line with national guidance within the resuscitation area, rapid assessment and treatment area, or triage room. Leaders told us the trust’s medical gases committee had undertaken work to improve storage arrangements and ensure appropriate facilities were available.

Further improvements were required to support the safe management of patients' own medicines. In February, we raised this concern with the provider regarding patients own medicines, they assured us these would be stored securely.

During our follow-up assessment in March 2026, nursing staff told us this process had not been implemented consistently, we were not assured that the provider had taken the necessary action.

We reviewed the department's controlled drugs governance arrangements. The provider told us controlled drug audits were undertaken electronically and included functionality to record actions and monitor progress where concerns were identified. However, this functionality was not consistently in use. Despite this, our review of controlled drug stocks found records were up to date and we identified no discrepancies.

We reviewed the service's response to medicines incidents. Data provided by the trust showed 38 medicines-related incidents had been reported during the previous six months. Whilst the trust had summaries of incident themes, there was limited evidence demonstrating how learning had been translated into measurable improvements. Action plans did not include completion dates, designated leads, or mechanisms for monitoring progress.

Medicines were primarily stored within electronic medicines cabinets which incorporated security controls to restrict access. Following our assessment, the provider undertook a review of system settings to ensure all available security features were being utilised appropriately.

We reviewed medication refrigerator temperature monitoring records covering the period August 2025 to February 2026. Whilst there were some gaps in recording, we saw evidence that these had been identified and actions taken to improve compliance. Room temperature monitoring records for medicines storage cupboards showed some inconsistencies in documentation during the same period. Although oversight arrangements were in place, recording was not always completed consistently.