Birmingham Children's 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

Safe is rated as requires improvement. This meant there was not always a strong awareness of safety hazards and the risks. The service did not always make sure that medicines were safe or met people’s needs and preferences. The service did not always make sure that staff had completed mandatory training specific to their roles.

However, solutions to risks were developed collaboratively, with the right people and system partners who could make improvements. Staff and leaders responded positively when people raised concerns about safety and ideas to improve care delivery were raised. The primary response was to view these as an opportunity to learn and improve continuously.

The service mostly had enough nursing, medical and support staff with the right qualifications, skills, training, and experience to keep patients safe from avoidable harm and to provide the right care and treatment. People were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. Environments, and equipment, were safe and designed to meet the needs of people using the service.

Staff had a good understanding of how to report incidents. They said they received feedback from managers, and updates on any outcomes or learning that was identified.

At our last assessment we rated this key question requires improvement. At this inspection the rating remained requires improvement.

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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff had a good understanding of how to report incidents. They said they received feedback from managers, and of any outcomes or learning identified.

Safety was a top priority that involved everyone, including staff as well as people who used the service. There was a culture of safety and learning. This was based on openness, transparency and learning from events.

Staff held daily safety huddles and handovers. During staff huddles, incidents were routinely discussed. We observed staff discussing an incident that had been reported using the patient safety incident response framework (PSIRF). The outcome of the investigation was shared with the team, and feedback was given on changes to be implemented from the learning.

Staff stated that incidents were discussed openly. They felt there was a ‘no blame’ culture. We saw reports from 3 patient safety incident investigations (PSII), these had been investigated thoroughly with areas for improvement and safety actions which had been completed.

Notice board displays in ward areas detailed incident reports and actions to be taken, for example, keeping bed spaces clutter-free to prevent accidents. There was information on the process to follow if a patient was unable to wear a wristband and the alternatives to be discussed with the patients and parents.

Incidents were reviewed to assessed seriousness, identified themes, and supported learning and improvement when things went wrong. There was evidence of actions taken in response to incidents, including discussions at team meetings and staff attending refresher training.

The surgery division reported an average of 219 incidents per month between July and September 2025, totalling 657 incidents. Incidents were categorised by level of harm. Of the incidents reported, 112 resulted in harm.

The most common incident themes were:

• 19% related to medication
• 11% related to follow up delay or failure in care
• 8% related to communication
• 6% related to access to services
• 6% related to staffing and skill mix deficits.

One of the themes identified from the reported incidents was delays in patient follow up. This issue was recorded on the service risk register for monitoring and actions were planned with the outpatient department.

The liver biopsy protocol had been reviewed as part of an incident investigation. This had been updated and staff had received learning from this incident.

We reviewed 20 sets of minutes and actions from morbidity and mortality meetings across a range of surgical disciplines within the trust. Case reviews within the minutes demonstrated learning and reflective practice. Topics covered included the duty of candour, its application and best practice, as well as local audits, findings and resulting actions.

Case reviews were clinician-led and supported discussion of patient outcomes and identification of clinical risks. Learning relating to medications and procedures was shared with staff. There was also evidence of a child death review, with learning from the investigation shared to support service improvement.

All staff understood their responsibility to be open and honest with patients and their families when things went wrong. Staff were able to explain and give examples of instances of applying the duty of candour and they had a good understanding of when this duty needed to be applied.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when people moved between different services.

Safety and continuity of care was a priority throughout the care journey of children and young people. There were good systems to support patient pathways. The service had good links with external agencies and community teams.

Staff had access to support from mental health, safeguarding and occupational therapy teams. They were able to identify who the designated service leads were for these services and told us they were responsive to requests for support for a child or young person.

The service had clearly defined pre‑operative assessment and post‑operative processes. There were comprehensive procedures and multiple care pathways to reflect the different types of surgery provided.

Pre-operative assessments ensured every child received a thorough medical review, was fully prepared for surgery and had time to ask questions. The pre-operative assessment process also contributed to reducing patient waiting times prior to surgery, supporting the smooth running of theatre schedules, and minimising cancellations on the day of surgery. Furthermore, these assessments helped to lower non-attendance rates and enhance the overall experience for both patients and their families.

The service had appropriate standard operating procedures to ensure patients were admitted safely and in a timely manner based on their clinical need. There were established arrangements to open or ‘flex’ beds in other areas to manage increases in demand, with oversight provided by the Divisional Management Team. In addition, there were procedures to ensure appropriate clinical oversight for patients who could not be accommodated on the relevant specialty ward. Their care continued to be managed by the responsible specialty team.

Children, young people and their families were involved in discharge planning. The service had systems to support young people transition to other services. For example, at the age of 16 years old it may be decided a young person could move to adult services. These decisions were led by the speciality nurses in connection with discussions with patients and their families and through the transition clinic. However, this decision was based on multiple guiding factors which were taken into consideration and not the age alone. Other factors included developmental readiness, the young person’s wishes, communication needs and cultural context.

Where required, children were referred to additional health professionals to support a smooth and well‑coordinated admission process. The assessments also supported nurse‑led discharge and helped prepare patients and families for both admission and discharge.

Care and support were planned and organised with patients, partners and communities to ensure continuity. The service worked well with other departments in the hospital and with other NHS trusts.

If the service had a child on the palliative care pathway their needs were discussed at multidisciplinary team meetings, any family needs such as accommodation were discussed. Cultural needs were also considered and adjustments made. Children on the palliative care pathway could be accommodated in Magnolia House, this was a dedicated palliative care, end‑of‑life, and bereavement support facility located within the hospital. It was designed to provide a calm, homely, and private environment for children, young people, and families. Magnolia House offered private counselling rooms, a family lounge, a siblings’ play area and a peaceful landscaped garden. Families could access therapeutic support such as counselling, play therapy and quiet reflection time with specially trained staff.

Staff held daily safety huddles and handovers. We observed a morning handover which was well attended by staff. Areas discussed included patient-specific concerns, such as any deterioration in theatre recovery, clinical observations, arrangements for onward discharge or transfer, safeguarding considerations, and relevant test results. Additional support services for patients were also discussed; one patient was having input from a dietician and occupational therapists.

There was a daily consultant led ward round at 10am which included the ward manager, medical and surgical consultants and clinical teams. Each Friday the ward round was multi-disciplinary and included consultants, dieticians, occupational therapy teams, family support teams and hepatology staff. Notes from ward rounds were entered onto the electronic patient record, staff were able to view these notes after to confirm actions to be taken.

During the daily medical meeting, patients scheduled for review that day were discussed, and their ongoing care and discharge planning were considered. The meeting also included a dedicated review of interventional radiology (IR) patient lists to support coordination of care and prioritisation.

Interventional Radiology (IR) is a specialist service that uses advanced imaging techniques, including X-ray, CT, MRI and ultrasound, to guide the diagnosis and treatment of conditions through minimally invasive procedures.

There was a missing child policy which clearly set out the steps to be taken in the event of an alert being raised. It outlined the responsibilities of the trust and its staff and identified the other services to be contacted if a child was missing. The policy was ratified and in date.

Staff 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 demonstrated a good understanding of safeguarding procedures and different forms of abuse. They could easily identify the service safeguarding leads and teams, how to get support and report a concern. There was evidence of actions taken to safeguard children and keep them safe from harm. For example, safeguarding referrals were immediately raised for dog bites, and these would also be logged internally and with the police. This was best practice guidance for safeguarding where a child has been bitten by a dog.

The service had a standard operating procedure for safeguarding and for children attending the service in crisis. For example, children who had or were declaring suicidal ideation or self-harm, or where a child or young person was already known to other local authority services.

Most but not all staff had completed safeguarding training in line with the trust target. The lowest compliance was for Safeguarding Children Level 3 and Safeguarding Adults Level 2 within medical and dental staff, recorded at 68.6% and 66.5% respectively for the period September 2025 to January 2026. Staff completion rates for PREVENT Level 3 training (recognising the threat of terrorism and extremism) for clinical staff met the trust target, with all areas achieving over 85% completion.

Staff demonstrated a good understanding of the Mental Capacity Act and its application. Training on the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) was included as part of the safeguarding training adults. However, this training did not meet the trust compliance level.

Patient records clearly identified and flagged any safeguarding involvement on the children and young people’s records. These were easily identifiable to staff so they would not be missed.

The service monitored all safeguarding referrals and supported staff when they had any questions or queries, or if they were not sure of the next steps.

The service raised referrals for children or young people where Female Genital Mutilation (FGM) was a concern. There was an FGM Policy and a specific paediatric FGM pathway for making safeguarding referrals.

A safeguarding audit conducted in January 2026 found that the quality of referrals was rated as either good or outstanding in 83% of cases. The service performed particularly well in relation to gaining consent, the clarity and detail of the concerns raised, and outlining what would happen next. Areas for improvement were also identified and acted upon, including the need to more consistently capture and evidence the voice of the child.

We saw evidence of safeguarding case discussions in departmental meeting minutes. For example, where the plastic surgery team had been contacted for an opinion on an injury to a child. The minutes reflected the decisions made, the reflective practice and the learning. There was also evidence of multi-disciplinary team working and good practice.

The service had effective systems for monitoring and treating patients. Risks were assessed, and staff understood them.

We observed staff completing clinical checks prior to surgery. Staff completed the World Health Organisation (WHO) surgical safety checklist. This is a tool designed to reduce surgical errors, complications, and mortality. Of the 5 WHO safety checks observed, staff correctly completed the ‘sign in’ stage prior to surgery. This check verified the patient’s identity, surgical site and type of procedure. Safety checks were carried out before, during, and after surgery. The details were accurately documented in the patient’s electronic record.

Staff we spoke with demonstrated an understanding of the National Safety Standards for Invasive Procedures (NatSSIPs2), including the key safety checks that support and extend the WHO surgical checklist. These checks were performed for every patient having an invasive procedure; this practice was embedded with surgical teams. The checklist was recorded on the electronic patient system.

The service completed audits of the WHO safety checklist. Audits for September, to November 2025 showed 100% compliance.

We observed 3 patients (with the consent of their parents or carers) on their journey to theatre and into the recovery area. The children and young people were given explanations of what was happening and where they were going.

In the main surgical suites, there were dedicated emergency theatres, these were sometimes called CEPOD or C-POD theatres and were aimed at preventing emergency surgery disrupting elective theatre lists. CEPOD theatres were staffed 24 hours a day, 7 days a week.

The service had a deteriorating patient pathway known as the Observation, Monitoring and Escalation Policy. Staff were able to explain this pathway and demonstrated an understanding of how to escalate concerns when a patient’s condition deteriorated. The pathway also acknowledged that there were times when parents or carers had concerns or felt that something may have been missed in their child’s care, this explained the action to be taken to address these concerns and escalate, if necessary to senior staff or medical teams.

The service used the “Listening to You” system, which allowed parents or carers to escalate concerns if they felt their child was deteriorating and wanted a second opinion. Staff also demonstrated a good understanding of Martha’s Rule, a patient safety initiative that enabled patients, families, carers, and staff to request a rapid review by a critical care outreach team when there were concerns about a patient’s condition.

Staff reported that, during kidney transplant procedures or treatment, concerns could be escalated and support requested as required. A consultant nephrologist was always on call to provide specialist oversight and guidance.

Patient records showed observations for monitoring patients’ vital signs and assessing the risk of deterioration was carried out a timely way. Observations using the paediatric early warning scores (PEWS) were entered and updated on the electronic patient record system.

We reviewed 12 patient records and found they were detailed and up to date. Records included patient medical histories, clear information on the patient’s condition and procedures, observations and test results. Fluid balance charts and nutritional needs were also clearly documented.

Staff told us that patient risks were assessed such as the risk of rejection following transplants and sepsis. As part of our inspection, we requested the sepsis audit results and action plans for wards, theatres and recovery. The service advised that routine sepsis audits were not currently undertaken across all service areas. This means that compliance with sepsis protocols, such as timely observations, appropriate escalation, and prompt treatment is not routinely monitored or assured. This lack of consistent oversight may result in variation in practice across departments and limits the service’s ability to identify risks, ensure adherence to standards, and drive quality improvements in patient care. They explained that they were establishing a trust-wide sepsis working group, reporting to the patient safety committee. This group will lead the development, coordination and rollout of sepsis audit activity and wider improvement work.

The sepsis policy required a full set of observations and a PEWS recorded for all patients, unless an exception had been documented and agreed with the patient’s medical team. This included key observations and clinical assessments. While the service was unable to provide the sepsis audit, they did provide audit results for:

• Cannula Care
• Care and Communication
• Drug Administration
• Hydration and Nutrition
• Hygiene
• Pain Management
• Patient and Parental Engagement
• Patient Observations
• Skin Care / Tissue Viability
• Falls and Patient Handling

The service scored well on these audits. Results over a 3 month period from October to December 2025 ranged between 93% and 98%.

As part of our inspection, we requested the PEWS audit results and action plans for wards, theatres and recovery. The trust advised us that the service had launched the Nursing Care Quality Indicators (NCQI) programme, which was a new audit framework. As the NCQI audit went live on the month of our inspection there were no audit results. However, during our review of patient records we found that PEWS scores were being monitored for patients and concerns escalated to senior medical or nursing staff.

Individual risks to children and young people were assessed, and patients’ families and their carers were involved in this process as much as possible. For example, the use of bedrails to keep babies or children and young people safe. The risk of falls were assessed in a specific way for children and young people. the service audited the falls risk assessments and results were consistently high across the wards and theatres.

The service had a sedation policy for use when scanning patients and staff were able to explain this and the associated processes. Staff explained that sedation was prescribed in line with the policy. Staff told us if they had concerns about a patient post procedure who was still appearing sedated, they could contact the anaesthetist team, who would attend promptly to review the patient.

We reviewed the record for a patient who had attended for a liver transplant. The record showed that all appropriate checks and risk assessments had been completed prior to surgery. The WHO checklist was completed, including documentation of blood tests, antibiotic prescribing, nil-by-mouth status, and consent, which had also been confirmed with parents or carers.

The service worked with children, young people, their families and other community and NHS providers to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Medical records we reviewed detailed good mental health support, safeguarding records were completed, and there was evidence of psychiatric support where required. There was good multidisciplinary team working both with internal trust teams and external support agencies.

The service kept records and monitored the use of restraint if it was needed to manage risks to a patient and staff. Restraint was only used as a last resort. The service had a use of force policy which stated that the primary response should be prevention and de-escalation. Assessments were documented and the type and reason for restraint was recorded. There was a post- incident meeting review after each time restraint had been used. The review considered what could have been done differently and any learning from the incident. In the 6 months prior to our inspection the service had reported using restraint on only 1 occasion.

Children and young people were cared for in environments that were designed to meet their needs and were safe. The service detected and controlled potential risks in the care environment. Staff made sure equipment, facilities and technology supported the delivery of safe care.

The service had suitable facilities to meet the needs of children and young people. The environment was visibly clean and designed with children in mind, such as soft colours and paintings of characters on the wall. All areas were clean and bright.

Ward 17 and surgical theatre suite mainly admitted day cases. There was an 18 bedded ward area, 3 operating theatres each with an anaesthetic room, a preparation room and a scrub area. The recovery area had 6 bays which could accommodate a patient trolley and the necessary monitoring equipment. Red ‘grab bags’ were used when transferring patients back to the main ward areas. The bags contained emergency equipment, wound care supplies, or surgical instruments.

Other theatre suites we visited had main surgical areas which were well equipped in accordance with national guidelines. Each one had a separate scrub area, and recovery bay. Theatres 14 and 15 were used for various speciality procedures but mainly trauma and orthopaedic elective procedures. The recovery area had 6 bays and 2 isolation cubicles for patients with infectious diseases, those who require a low stimulus environment, or bereaved families.

In all areas, electrical equipment had been tested and labelled to show it was safe to use. Equipment was in good condition, had been serviced, and the servicing date was visible on the equipment. Logbooks for anaesthetic equipment had been completed accurately and kept up to date. Completion of anaesthetic equipment logbooks and accurate recording of the renal circuit number indicated that necessary maintenance and safety checks had been done.

Storerooms and utility rooms were clean and well organised. Surgical packs were kept in storage which was off the ground and the temperature was controlled. Utility rooms had clearly marked areas for clinical waste, and these were locked and removed at the end of each day.

Following a surgical procedure, dirty and used instruments were bagged and stored securely to be decontaminated off site.

Cleaning products which might be harmful were stored correctly in line with the Control of Substances Hazardous to Health Regulations 2002 (COSHH). Any products were kept in a cupboard in a room with swipe card access only. Treatment rooms were locked with a coded keypad for staff access only.

Anaesthetic rooms were well equipped and cupboards containing medication including controlled drugs were locked securely.

Ward 8 was a 15-bedded ward which included a 5-bedded high dependency unit. This was used for patients following transplantation or major liver surgery. There was a 12-bedded ward renal ward.

The surgical day case unit had capacity for 14 patients but could be used for 18 patients if needed. They carried out procedures including scans, computed tomography (CT) scans with sedation or general anaesthetic.

Leaders and staff considered how environments could keep children and young people safe from harm and in relation to supporting their sensory needs. The windows on all wards were safely secured to prevent the risk of falls. The ward staff had access to sensory toys, ear defenders and weighted blankets to support any children and young people who had additional sensory or other needs. There was a hoist to help move children and young people safely who could not weight bear.

Resuscitation trolleys were in good condition, equipment was in date and daily checks had taken place. We also reviewed the difficult intubation trollies which were checked daily and appropriately stocked.

Notice boards in the wards and theatre areas displayed details of which staff were working that day. It detailed the nurse in charge, staffing actual compared to planned. There was also a section for suggestions from patients called ‘you said, we did’. An example of you said, we did was reminders to staff to keep noise at night to a minimum when patients were resting, the service had responded by providing earplugs if needed.

The fire evacuation procedure was displayed in all areas, and we noted fire doors were not obstructed and extinguishers where in easy reach. Wards had fire wardens to take the lead in the event of an evacuation.

Entrances were secure and children were kept safe. Ward entrances were locked, and visitors needed to use the intercom to enter after they verified who they were and who they were visiting. There was a security camera at the staff workstations, so staff could check who was at the door.

Fridge temperatures were monitored and checked in line with national guidance.

The service completed a comprehensive ligature risk assessment across all inpatient areas. An experienced mental health nurse was engaged to support the identification of potential ligature points and ligature risks within ward environments.

Actions were taken to mitigate identified risks to patients. These included processes to assess and recognise individuals expressing suicidal ideation, removal of potential ligatures from the patient’s immediate bedspace, and the use of appropriate levels of observation and supervision to maintain patient safety. Resus trollies in these areas were also equipped with ligature cutters.

The service mostly had enough nursing, medical and support staff with the right qualifications, skills, training, and experience to keep patients safe from avoidable harm and to provide the right care and treatment.

There was appropriate nursing skill mix to make sure patients received consistently safe, good quality care that met their needs. However, there was a reliance on bank staff for theatres which represented an equivalent of 6.8 full‑time posts, in the theatre teams. Some of this shortfall had been attributed to moving to a 6‑day working week for increased productivity and capacity but had added staffing pressures.

The service provided evidence to demonstrate that it was in an improving and positive position with nursing recruitment overall. Most remaining vacancies were within theatre services. The trust recognised the associated risks and had plans to mitigate these and support further improvement. Staffing risks and the possible impacts on patients were identified on the service risk register with actions to be taken and to mitigate risk.

The trust had identified theatre staffing as a key risk and implemented mitigation measures where possible. This included reviewing workforce roles and aligning them more closely with the operational needs of theatre teams. For example, some Band 7 specialist scrub roles were reviewed and appropriately redesigned as Band 6 roles where this better reflected service requirements, supporting workforce sustainability while maintaining safe care delivery.

They had also reviewed workflow to help with capacity and efficiencies. For example, they had increased the cardiology pre-admission staffing and introduced a structured cardiac surgery pre-admission service to improve patient preparation, admission flow, and peri‑operative safety for cardiac surgery patients.

There was a daily bed meeting where staffing levels and needs in particular areas were discussed. Where bank staff were needed the service used staff who were familiar with the ward or surgical area. Managers checked staff were trained and competent to administer intravenous medications. Staffing for the day was discussed to ensure this met patient needs and safe staffing requirements.

Staff we spoke with told us they were sometimes asked to work in different areas if there were staff shortages. They were happy to do this and were only asked to move to areas where they had experience and knowledge of the ward. The nurse in charge of each ward or unit reviewed staffing levels daily, took into account patient numbers, acuity, clinical urgency, and the level of nursing care required. Any short fall in staffing would be escalated to the surgical flow coordinator, lead nurse and head of nursing at daily bed meetings and, where necessary, staff were requested from other areas to help.

We observed one theatre being prepared for surgery and staffing levels were in line with the Association of Anaesthetists guidelines. The staffing skill mix across theatres, wards and surgery were reviewed in line with national guidance and the Royal College of Nursing standards to ensure staffing roles and competencies matched service demand and supported safe patient care.

The service had a learning and disability lead nurse and a learning and disability liaison worker who worked with patients and their families to discuss support needs and make reasonable adjustments.

Staff received training that was appropriate and relevant to their roles and were given protected time to complete this. The service provided mandatory training that was suitable to meet the needs of children and young people using the service.

The trust target for mandatory training compliance was 85%, and most training modules met this target. However, compliance for some modules was below the trust target. In the 6 months prior to our inspection, Sepsis 6 training averaged 79.7%, Venous Thromboembolism (VTE) training 61.4%, and medicines management training 65.1%. The low compliance for medicines management training was reflected in this being the highest of the incident themes reported. The service did not have an action plan for improvement of this training compliance rate.

Records showed that staff had completed mandatory hospital life support training in line with organisational requirements, this includes basic life support (BLS) immediate life support (ILS) and advanced life support (ALS) training. In the 6 months prior to our visit, an average of 89% of staff across the hospital’s medical and nursing teams were compliant with their hospital life support training.

Staff spoken with confirmed they felt confident in recognising and responding to medical emergencies, which supported patient safety. In the 6 months prior to our visit, an average of 89% of staff across the hospital’s medical and nursing teams were compliant with their Basic Life Support training.

The service also had 43 staff trained in European Paediatric Life Support (EPLS) and 18 staff trained in European Paediatric Advanced Life Support (EPALS). This ensured appropriate clinical expertise was available to respond to paediatric emergencies.

The educational leads provided support, and most staff told us they had the appropriate level of access to education leads and felt supported in their roles. However, some staff felt that due to staff shortages in some areas, education leads were covering clinical roles and therefore staff had reduced support.

Student staff also had educational support. Student nurses and doctors told us they felt they could ask questions and for feedback in a productive way. They felt supported by their peers and other ward staff. However, some trainee doctors told us that they had concerns about successfully completing some of their competencies due to the number of surgical cancellations. Trainee doctors needed to demonstrate a level of skill in procedures to pass. Lack of sufficient theatre time to perform these procedures could be detrimental to their learning.

Staff told us they had opportunities for career development and were able to attend additional training courses to gain further qualifications. Staff also confirmed that they received appraisals and had development plans in place.

Compliance data showed that most staff had received an annual appraisal. However, appraisal completion rates were lower in some areas, including Medical Secretaries, Ophthalmology, and Ward 17.

Staff were able to easily identify the leaders and managers within the service and the roles they had within the organisation. Staff could name the safeguarding and clinical speciality leads and the heads of departments as well as their own direct managers. Ward and theatres staff names were displayed on ward corridors for the information of patients, visitors and other non-surgical staff members.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of spreading infections and shared concerns with appropriate agencies promptly.

There was good identification of possible risks from infection and staff took safety precautions. The ward clearly identified rooms where children or young people were isolating if, for example, if they had been diagnosed with influenza. Patients were assessed if they had been travelling in the last 12 months or if they had been an inpatient in another hospital. Communicable disease screening was done for every admission.

Staff washed their hands before contact with a child or young person, and once the treatment had finished.

There was a good standard of cleaning. All areas and equipment were visibly clean, and equipment was clearly labelled with an ‘I am clean’ sticker, with a date to show when it had last been cleaned. Cleaning schedules clearly identified when rooms and equipment were due to be cleaned, and these were up to date. Cleaning rotas were available to view easily in each theatre.

The service had a schedule for cleaning and infection prevention and control (IPC) audits, with a different area audited each month. Between November 2025 and January 2026, 3 surgical wards were audited, with an overall compliance rate of 97%. Action plans with specific completion dates were implemented following the audits.

Staff used personal protective equipment and stored waste safely. This included wearing aprons, gloves, and masks and using these when required. There was antibacterial hand gel for visitors and staff to use. Visitors and people using the service also had access to handwashing facilities. The wards had an appropriate storage space for clinical waste, which had a locked door, and containers were emptied on a regular basis.

Boards in the wards displayed the results of audits. The boards also showed where audits had not met the expected standard and what actions were to be taken for improvements. This was a visual reminder for all staff of the goals for the ward and the outcomes from audits. Patients could also scan a QR code to see the IPC information for the ward. This included monitoring of surgical wound infection rates and other infection rates. The emphasis was on everyone working together to help prevent infections in hospitals.

The service isolated children who may have been in contact with measles in single rooms and there was access to personal protective equipment for staff and families.

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

Medicines were not always stored safely and securely. There was a lack of oversight and responsibility by ward staff to ensure that medicines were organised or stored safely. For example, across all wards visited we found loose strips of medicines and loose ampoules in cupboards and drawers which had not been returned to their original dispensed box. On one ward we found an intravenous bag of an antibiotic, metronidazole 500mg/100ml stored incorrectly in a drawer with 5% Dextrose 100ml bags. This was removed at the inspection. We found expired medicines which had not been removed or disposed of in line with the trust policy.

Medicines that required refrigeration were not always stored in a refrigerator. This meant they were potentially not safe to use. The medicine safe and secure handling audits undertaken by pharmacy every six months also highlighted and alerted staff to the same issues. However, there had not been any action taken at ward level to address them. Poor medicine storage is an unsafe practice and increases the potential for a medicine error.

Controlled drugs (CDs are medicines requiring more control due to their potential for abuse) were stored safely and securely with access restricted to authorised staff. Checks were undertaken and recorded by 2 staff twice a day which showed that they were within date and stock balances were recorded. However, we found items that were not controlled drugs stored in ward CD cabinets., This included money, vouchers, keys and staff’s own medicines. This increased the risk of unnecessary access to CDs.

On one ward we found a CD labelled for one patient with their name crossed through and another patient’s name written on the label. There was no record of who had made this change. This is poor practice and increases the risk of a CD error. Pharmacy undertook CD audits every 3 months to check for safe CD compliance however these issues had not been identified and were not included in the audit checklist.

Resuscitation medicines required in an emergency followed Resuscitation Council (UK) guidance. Records were available of expiry dates for medicines and equipment which were all in date. Daily checks were made by staff to ensure they were safe to use.

Medicines for refrigeration were not always stored securely. Medicine room storage and refrigerator temperatures were monitored with records available of maximum and minimum temperatures to ensure the medicines were stored safely. However, we found that maximum and minimum temperatures were not always recorded and there were some omissions in records. We found one ward where the room temperature was recorded above the recommended safe level, but no action was recorded to show if staff had followed policy to ensure medicines were safe to use.

Processes ensured people received their medicines as prescribed. A new electronic prescribing system had recently been initiated as part of the electronic patient care record. Overall nursing staff said it was helpful and supported ensuring the right medicine was administered to patients. It also highlighted when a medicine should not be administered, if it was too close to the previous administration. We were shown how this worked for paracetamol, where the system gave a red warning if a dose was going to be given before the 4-hour time limit. This was a helpful safety warning for staff. However, the pharmacy team did not have the time or resources available to undertake the necessary ongoing work that was needed to ensure the electronic system was kept up to date. There was no dedicated digital pharmacist or pharmacy technician in post to have oversight of these issues and be able to resolve them. This would enable clinical pharmacists to have dedicated time to undertake their ward-based roles.

Patients were supported to receive their prescribed medicines in a way that met their individual needs. One relative told us that they were included in discussions about medicines and stated “the whole journey has been very impressive and I have no complaints”

Parents and carers had access to a ‘My Chart’ app, which they could sign up to and agree to use. It enabled families to message the medical teams directly, improving communication.

Staff told us that they knew how to contact pharmacy for advice and there were processes for the supply of medicines. Staff told us there was a pharmacy presence on most wards, however not all wards had a dedicated clinical pharmacist visit due to a lack of funding. Staff on the liver unit commented that although they did have pharmacist cover, a dedicated liver specialist pharmacist would help with support and advice on the complex prescribing issues. Nursing staff also said that the pharmacy department was available to support them with managing medicine processes such as ordering and receiving medicines if needed.

We reviewed 15 medicine administration records. They were documented correctly with the route and time of administration, including recording a reason if a medicine was not given or for ‘self-administration’ by a parent. Nursing staff found the timeline for administration and the ability to leave notes for medical staff to review a patient helpful. However, reviews of prescribed medicines by clinical pharmacists were not always being undertaken. We found records on the system ‘Awaiting Pharmacy Screening’ for several days at a time. For example, one patient prescribed an antibiotic, which required careful monitoring and dosing, had not been checked or reviewed by a pharmacist for two days, which is not in line with national guidance.

Nurses had access to online medicine guidance to ensure they were using the most recent up to date information for the safe preparation and administration of intravenous (IV) medicines. However, on one ward we found an out-of-date paper copy of a medicine protocol (dated 2010) which was being used as the primary source of information. Staff could not locate an up-to-date online protocol for the medicine preparation. During our inspection this was escalated to the pharmacy team for review.

Medicine reconciliation (the process of gathering a complete list of people’s prescribed medicines) information was not always recorded as being undertaken. The national target is that 100% of patients admitted receiving medicine reconciliation within 24 hours of admission. We found that these details were not always available or difficult to locate which would help to ensure patients medicine records were accurate and ensure patients didn’t go without medicines when admitted to the ward. Following the inspection, information was received from the pharmacy which highlighted that further work was being undertaken to use the data to reflect practice, and a staged plan was to be agreed with the trust, however this would need investment.

Incidents reported on the new electronic system were not categorised to identify medicine-related incidents, which made it difficult to review any emerging themes or check for medicine incidents.

Patient Group Directions (PGD’s) were available. PGDs are written instructions for the administration of authorised medicines to a group of patients. This meant medicines were administered to patients by staff with the legal authority to do so.

Patients weight was recorded as standard on all medicine administration records. This is important for calculating weight-based medicine prescribing. Paracetamol guidelines had also been recently updated with further details about weight-based prescribing, which we were told by pharmacy teams had led to a decline in reported incidents with paracetamol.

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

There was a clear discharge process for medicines. Medicines for discharge were screened and checked for accuracy by clinical pharmacists. Information was provided to parents so that they had all the necessary information about medicines. Some wards had a supply of ready pre- labelled medicines, such as pain relief or antibiotics, which could be given to patients at discharge to reduce waiting times from pharmacy.