The Princess Alexandra Hospital

On this page

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

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

At our last assessment in March 2023, we rated this key question requires improvement. At this assessment the rating has remained requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service requires improvement in keeping people safe. Risks were identified in patient flow, environmental safety, infection prevention, and medicines management. Ambulance handover delays, corridor care, and limited mental health provision compromised safety. Inspectors also observed non-compliance in hand hygiene, unsecured equipment, and expired or missing emergency medicines, all of which increased clinical risk. Although leaders had action plans and improvement programmes in place, these were not fully embedded at the time of inspection. Despite these concerns, we saw evidence of staff striving for a positive safety culture. For example, safeguarding concerns were escalated promptly and staff participated in regular training and development to maintain safe staffing.

We have not awarded this service a score for Safe.

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

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

Leaders took a structured approach to learning. Leaders attended a range of meetings to ensure a learning culture. For example, leaders attended monthly Patient Safety and Quality (PSQ) meetings. Leaders reviewed safety, patient experience, and risk information. We looked at data, minutes, and action logs from April to October 2025 which showed consistent learning activity.

Staff received monthly incident learning summaries and internal safety bulletins where repeated themes required clear actions, deadlines, or staff reminders. Leaders shared a comprehensive learning report, summarising learning from incidents, complaints, and positive feedback. Leaders set goals for 2025, such as reducing inpatient falls, preventing hospital‑acquired pressure injuries, and improving the timeliness of critical medications.

Incident data showed active reporting and improved investigation performance. In July, 149 incidents were reported: 124 (83%) caused no harm, 18 (12%) resulted in minor harm, 6 (4%) in moderate harm, and 1 (1%) in severe harm. In September, 135 incidents were reported: 110 (81%) were no‑harm and 25 (19%) were minor harm, with no incidents resulting in moderate or severe harm.

Investigation teams improved their in‑month completion rate from 81 incidents (54%) in July to 103 (76%) in September. Incidents under review fell from 68 (46%) to 32 (24%), showing sustained attention to backlog reduction. 186 incidents were closed in July and 135 in September, demonstrating continued oversight.

In September 2025, staff reviewed 8 violence and aggression incidents, 14 inpatient falls (3 under investigation), 13 medication incidents, 3 infection‑prevention incidents, 3 self‑harm incidents, and 11 corridor‑care incidents. Leaders monitored repeated issues, particularly falls, isolation challenges, and corridor care, and used this information to clarify expectations and improve practice. Of 31 incidents escalated to the Incident Management Group, 7 required deeper review.

Shared learning was embedded across teams. For example, ward teams discussed medication errors and agreed corrective actions. Daily huddles and monthly nursing meetings highlighted issues such as incomplete property forms and infection‑control gaps, helping staff prevent repeat errors. Multi-Disciplinary Team (a group of different health professionals) meetings supported shared governance, and weekly simulation reinforced learning from previous incidents, supporting staff confidence in emergency scenarios.

Complaints teams reviewed concerns weekly, with clear actions agreed. Staff described understanding Duty of Candour requirements, and audits showed this was monitored. Duty of candour is where staff explain how errors were discussed openly with patients and families, promoting transparency.

Between 1 November 2024 and 31 October 2025, the Adult Emergency Department (ED) received a total of 59 formal complaints, of which consent to proceed was not received for 5 cases. In total, 55 cases were closed. As of 01 December 2025, 7 cases remained open and under continued investigation.

Staff reported feeling comfortable raising concerns and described leaders as approachable and supportive. Patient and staff feedback influenced decision‑making, such as improving waiting‑area signage after concerns were raised. Policies for paediatric emergencies, including anaphylaxis, trauma, and asthma, were up to date and accessible.

Leaders and clinical staff attended Morbidity and Mortality meetings, ED specialty meetings, and PSQ oversight. We saw that clinical staff attendance at some specialty meetings was low, which limited assurance that learning was consistently shared across all teams and disciplines.

We scored this quality statement as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Ambulance handover data showed increasing operational pressure through the second half of 2025. Mean daily handovers over 45 minutes rose from 7.43 in June to 21.63 in November. This pattern was consistent with rising seasonal demand heading into winter. The data also suggested inconsistent use of the Ambulance Cohort Area process and reduced flow through the emergency department.

Leaders shared up‑to‑date data showing average handover times had risen to 1 hour 10 minutes, with the longest delay reaching 6.8 hours. These delays increased clinical risk and disrupted continuity of care. During this period, patients who remained on ambulances continued to receive care, including 2:1 monitoring from ambulance staff and review, diagnostics and treatment from the ED team when required. However, care delivered in ambulances was not a substitute for timely admission to appropriate clinical areas. Prolonged stays still created risks related to environment, capacity and supervision.

Refurbishment work in Majors 2 meant the corridor space was also used to care for patients. Staff worked to deliver required treatment in this environment, but it contributed to crowding and created additional hazards for patients and staff. Wider hospital pressures and limited inpatient capacity continued to affect patient flow. Leaders reviewed processes to improve consistency and safety, but patients still waited too long to enter the department.

Staff managed some patients transferred into the Emergency Medicine Same Day Emergency Care (EM SDEC) area outside the main Urgent and Emergency Care (UEC) tracking system for extended periods. This meant these patients were not consistently visible on the usual monitoring tools. As a result, staff could not assure us that deterioration would be recognised promptly or that escalation would occur without delay.

The Ambulance Handover Working Group’s review found several issues in the safety system that affected how smoothly patients moved through their care pathway. Staff did not always follow the Standard Operating Procedure (SOP) in the same way. Some ambulance crews varied in how they carried out handovers. There were wider problems, such as blockages in the emergency department and a lack of alternative routes for redirecting patients safely. These gaps in the system meant patients did not always move through the service as planned, causing delays at key points in their care.

Since 4 November 2024, leaders monitored ambulance handover performance daily using dashboards. Staff used ambulance provider data and statistical process control charts to identify trends, early warning signs, and confirm whether improvement actions were effective. Weekly regional NHSE ambulance handover packs were also reviewed. Leaders explained that this continuous monitoring replaced the need for separate audits and formed part of the UEC improvement programme, aiming for zero handovers over 45 minutes and a 30‑minute average by March 2026.

Leaders provided refresher training, improved communication with the ambulance service, and updated the escalation and surge plan. These actions reduced mean daily delays from 21.53 Hours in November 2024 to 7.07 in April 2025; between April and July 2025, delays remained stable at 7–9 hours per day. Live dashboards allowed staff to monitor daily ambulance delays, enabling early action and checks on whether improvements were working.

Staff faced significant system‑wide challenges securing timely mental health admissions. This affected the continuity and safety of care for patients who required specialist support. We saw examples where patients remained in the department for many hours, and in one case almost four days, while awaiting a mental health bed. These prolonged waits increased distress and heightened associated risks, despite staff putting measures in place to maintain safety.

Patients awaiting mental health admission received close supervision and appropriate support, with ongoing oversight from the mental health liaison team. Staff escalated delays through site‑level bed meetings, held at least four times a day, and maintained communication with the mental health provider. While these actions helped to mitigate immediate risks and no patient harm had been reported at the time of inspection, the ED environment remained unsuitable for prolonged stays. This reflected wider system pressures that continued to impact safe transitions and patient flow.

Although proactive liaison with mental health services occurred, constraints within the wider system limited the impact of these efforts, and some patients continued to experience prolonged waits.

Staff identified safeguarding risks promptly and escalated concerns to the safeguarding team. Young people were assessed with responsible adults present, and staff considered past experiences and preferences to meet individual needs. Referral and admission processes ensured essential information was shared and patients’ needs could be safely met.

Staff assessed each patient individually at first contact. In paediatric emergency care, triage was completed within the national 15‑minute target, including allergy checks, pain scoring, and safety netting. Leaders developed clear redirection pathways, and staff were trained in the Manchester Triage System with robust competency checks.

Leaders also monitored patient flow in real time using a colour‑coded escalation system. In the RAT area, skilled staff completed triage and National Early Warning Score (NEWS) assessments while maintaining privacy and dignity. Staff worked with healthcare and social care services to maintain continuity of care during admission and after discharge.

Mental health patients conveyed by ambulance were not offloaded into general waiting areas but taken directly to the major’s area where clinical staff could observe them continuously. This aligned with national guidance and reduced the risk of absconding. Clinical teams worked consistently with partner organisations to monitor risk, update care plans, and mitigate harm while awaiting appropriate placements. Mental health records were mostly person‑centred and included input from liaison teams, safeguarding professionals, and clinicians, supporting wraparound care.

We scored this quality statement 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.

Staff had access to an up‑to‑date safeguarding policy and clear lines of accountability, including designated leads and a named lead doctor. Staff understood how to identify adults and children at risk and demonstrated confidence in using established processes such as online referral systems, police welfare procedures, crisis lines, and triage safety checks. The trust safeguarding lead visited the department daily, providing accessible advice and support.

Records reviewed showed that concerns were escalated promptly, with information consistently shared with the safeguarding team and the local authority. Staff demonstrated good practice by involving social workers early and liaising closely with ward teams and adult social care providers, ensuring people remained safeguarded throughout their care and at discharge.

Between November 2024 and October 2025, staff raised 126 safeguarding concerns related to risks such as neglect, domestic abuse, self neglect, and mental health crisis. Staff acted quickly and appropriately, and monthly activity reports demonstrated natural variation, including expected increases during periods of winter pressure. Reporting levels remained consistent, indicating an embedded safeguarding culture and strong partnership working.

Daily safety huddles, safeguarding training sessions, and regular support from the Safeguarding Adults Team helped increase staff participation in safeguarding processes and strengthened organisational oversight. The safeguarding team also updated and relaunched an evidence based supervision policy in summer 2025. Since then, 45% of eligible staff had received supervision, with higher uptake in priority areas such as the Children’s Emergency Department and Neonatal services.

Leaders identified that safeguarding training compliance required improvement. Emergency Department nursing staff Level 3 safeguarding compliance was 83%, against a 90% target, with 20 staff non‑compliant, primarily Band 5 and unregistered roles. Leaders implemented a targeted action plan to increase access to training, monitored compliance weekly, and escalated delays, noting that full compliance depended on all staff completing training within the 12‑month timeframe.

Medical staffing showed a similar pattern, with Emergency Department doctors reaching 82% compliance against the same 90% target. Twelve staff remained non‑compliant, prompting equivalent escalation measures.

While supervision uptake improved after the policy relaunch, overall compliance remained low at 45%. This was partly due to delays in policy ratification and turnover among supervisors. However, ad hoc supervision and mandatory paediatric sessions continued while the new model embedded.

We scored this quality statement 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.

Leaders demonstrated systems for identifying, managing, and mitigating risks, and staff undertook regular multidisciplinary reviews. However, there were gaps in how patients were meaningfully involved in understanding and managing their own risks while they were in the department. Although patients received a text message after discharge to provide feedback and PALs information was available, these mechanisms mainly captured views retrospectively. Patients did not always have accessible ways to share feedback about their care or raise concerns that might influence risk management.

Patients did not have simple, immediate options such as comment cards or other in‑department prompts to share concerns while present in the ED. While the digital Friends and Family Test and patient satisfaction questionnaire offered useful insight into overall experience, they provided limited information about patients’ perceptions of risk, safety or emotional needs at the point of care, reducing opportunities to identify risks from the patient perspective.

Staff did not offer comment cards or suggestion boxes, and leaders told us these had been removed because they were not generating useful feedback. While Digital Friends and Family Tests were available, this provided limited insight into patients’ experiences of risk, safety, or emotional needs and reduced opportunities to identify risks from the patient’s perspective.

Despite this, staff actively involved other professionals when needed. For instance, in one case involving a looked‑after child with high levels of risk. Staff assigned an additional nurse to provide continuous supervision and worked closely with Child and Adolescent Mental Health Services (CAMHS) to ensure both safety and emotional support. This demonstrated an ability to collaborate effectively with external partners to manage complex risks, even though direct patient involvement in risk planning remained inconsistent.

The service did not have a SOP for discharge from Urgent and Emergency Care (UEC), and the trust‑wide discharge policy had expired. Leaders told us an updated policy was in development and due for completion by March 2026. In the interim, a comprehensive four‑page discharge leaflet was available for patients and staff. The leaflet provided clear information on expected discharge timelines, early care‑planning discussions, involvement of family or carers, returning home or exploring alternative care options, and the purpose of timely discharge from hospital. It also explained the use of the discharge lounge and included contact details to support understanding and communication. This resource helped ensure patients received consistent information while formal policy updates were still underway.

Clinical teams worked proactively to support timely patient flow, including timely clinical decision‑making. Although patients were assessed, investigated, and either discharged or referred for admission, delays in securing inpatient beds or onward care pathways meant some patients awaiting admission remained in the department for extended periods. This resulted in crowding pressures and increased clinical and operational risk.

Care was not always delivered in line with best practice. Although mitigation measures were in place to reduce harm, nurses did not consistently follow guidance to minimise risk through timely transfer. Patients were not always transferred from emergency department trolleys to beds within six hours, which increased the likelihood of patient harm.

Staff told us that trolleys and beds in use had pressure‑relieving capability, and that vulnerable patients awaiting admission were prioritised for transfer when inpatient beds became available. Staff also used additional mitigations, including Repose overlays and regular repositioning, to reduce the risk of pressure injuries.

However, ongoing delays in securing inpatient beds meant some patients awaiting admission remained on trolleys for extended periods, beyond the six‑hour timeframe. While mitigations were in place, prolonged trolley care in a busy emergency department increased the risk of pressure injuries and contributed to overall clinical risk.

Staff explained care and treatment clearly and used effective communication methods for patients with additional needs, supporting understanding and safety.

Records reviewed showed documentation was complete, observations appropriate, and interventions timely in most cases, indicating some consistency in risk management.

Paediatric triage met the 15-minute national target, and staff interactions were polite and reassuring, with assessments completed and clear pathways for redirection in place, supporting safe care for children.

Staff understood the importance of Martha’s Rule. A national patient‑safety initiative, designed to ensure that concerns about a patient’s deterioration were heard and acted upon quickly. There was a SOP that applied to all staff involved in Martha’s Rule and the Call4Concern process. The SOP explained how the trust implemented the three core elements of Martha’s Rule in adult and paediatric inpatient areas. Including daily conversations with patients about how they felt and whether their condition was improving or worsening.

Leaders made sure all staff could request a review from another clinical team at any time. They could escalate if they were worried that a patient was deteriorating and felt their concerns had not been addressed. This helped remove barriers and supported a culture where staff were empowered to speak up early.

Patients, families, and carers could use the same escalation route, giving them the right to request an urgent review if they believed the patient’s condition was worsening. The trust clearly advertised Martha’s Rule across the hospital, using posters and visible information, so people knew how to get help quickly if they were concerned.

We scored this quality statement as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The Emergency Department (ED) faced several environmental and safety challenges. Staff managed regular incidents of violence and aggression. Staff reported, between September 2024 and September 2025, 3 to 18 incidents of violence and aggression.

Staff described these incidents as verbal abuse from patients and relatives, including shouting, rudeness, and aggressive complaints. The incident data did not specify where these events occurred.

During our visit, we saw staff carrying out observations in a small workspace located within the main waiting area. This space was separated from the public by a partial fabric screen but remained open and visible to all visitors. Staff told us they sometimes felt unsafe in this area, particularly when managing distressed or confrontational behaviour.

Security staff were always present in the waiting area, and staff told us this was helpful. The service had also begun trialling body‑worn cameras for nurses to further support staff safety. However, despite these measures, some staff continued to feel vulnerable due to the open layout and limited physical separation from the waiting area.

Staff cared for patients in corridor areas. This referred to corridor care, where treatment was delivered in non‑designated clinical spaces. Two corridors were in use at different points during the inspection period. Across the duration of our assessment, a total of 23 patients received care in these areas. This was the cumulative number and did not represent the number present at any one time.

We found that staffing arrangements for corridor areas varied. On one occasion, Corridor 2 was overseen by one registered nurse, supported by a nurse from another department. Leaders told us their intended staffing ratio for corridor care was a maximum of 1:4, and that corridors would only be opened when appropriate staffing or ambulance crew oversight was available to maintain safety.

The use of corridor space had been influenced by ongoing refurbishment work at the time of the inspection, which leaders reported was completed shortly afterwards. Leaders explained that, following completion of the works and the introduction of a revised surge plan, the need to use corridor space had reduced, and Corridor 1 had only been used in extremis and for short periods.

Nurses working in corridor areas did not always have immediate access to equipment at the point of care. During our visit, staff told us they sometimes needed to leave patients briefly unattended to collect items such as suction or personal‑care equipment, and we observed this in practice. Leaders explained that portable suction was available on resuscitation trolleys and had been moved closer to the corridors to support staff.

Staff moved through the corridor areas frequently, enabling quick identification of any concerns. They also told us that the use of corridor space had reduced following the completion of refurbishment works. Corridor 2 was no longer used and Corridor 1 only opened occasionally for short periods to support demand.

Senior nurses initiated a corridor‑care audit and reviewed patient risk assessments to support and improve these identified challenges. The Practice Development Nurse began patient reviews with findings scheduled for discussion with the senior team. Staff recorded corridor‑care incidents consistently throughout the prior 12‑month period. There were 99 incidents recorded during this period. Monthly totals ranged from a minimum of 2 incidents to a peak of 15 incidents in November.

This showed that corridor‑related risks continued to occur regularly across the year. In September 2025, staff reported a mix of incident types across the ED: 1 abuse incident, 2 access related incidents, 3 accidents that could have caused personal injury, 1 failed or delayed diagnosis, 1 monitoring or review incident, 1 resources‑related incident, and 2 medication incidents. The data shared with us lacked context about where or how these events occurred.

Leaders acted on recurring themes, and we saw this reflected in meeting minutes and action plans. For example, in response to medication‑related incidents, leaders had introduced additional safeguards such as requiring a senior nurse to complete double‑checks at the start and end of each shift. Pharmacy also undertook monthly audits to support oversight and learning.

Leaders identified three key learning messages for staff, strengthened daily safety checks, planned spot‑check monitoring, and committed to updating the standard operating procedure as part of a long‑term solution.

The paediatric team worked in a temporary area during refurbishment. We found aspects of the environment that created additional risks. The space was compact and had limited separation between clinical and non‑clinical functions. Staff initially told us they relied on a battery‑operated panic alarm in one room, which reduced their confidence in emergency response. Leaders explained that doorbell alerts had been installed across the children’s areas to support communication and that the children cared for in this space were assessed as low‑risk, with good visibility maintained by two registered nurses.

The temporary layout meant the paediatric resuscitation space was located within the doctors’ workspace. Leaders told us this had been risk‑assessed, a simulation exercise had taken place, and screening had been introduced to maintain privacy while enabling safe care. Fire exits that had been identified as obstructed during inspection had been cleared by the time we completed our visit.

Staff also experienced safety and dignity issues in the main waiting area. Healthcare Assistants (HCA) worked behind privacy screens but remained visible and audible to the public, meaning patient conversations could be overheard. HCAs had no panic alarm or call bell. HCAs reported feeling unsafe after incidents of verbal abuse, despite managers placing security staff nearby and positioning HCAs opposite the streaming nurse. Staff did not feel these measures were robust.

There were also gaps in equipment safety processes. Staff did not always complete defibrillator checklists, leaving gaps in compliance and increasing risk during emergencies.

The department had one designated high‑risk mental health cubicle, purpose‑built to provide a safer environment for patients with significant mental health needs. The cubicle was ligature‑free, had full 360‑degree alarm coverage, and allowed two‑way access to support both patient and staff safety. Staff told us that although this space was effective when used, it was not sufficient for the volume of mental health patients attending the department. As a result, they felt the wider environment did not always provide an appropriate or safe space, and this contributed to increased stress for staff managing complex presentations.

Leaders explained that patients were risk‑assessed on arrival, that not all mental health patients required this high‑risk cubicle, and that additional oversight was provided where environmental risks were identified. They also highlighted wider system pressures that affected timely access to mental health facilities, and noted plans to open a dedicated mental health urgent care facility in 2026, which was expected to reduce demand on the ED.

Reception staff managed a clean and well‑equipped waiting area with seating, waste bins, charging ports, vending machines, and safety glass.

Security staff provided 24/7 cover, and waiting times were clearly displayed.

Streaming nurses assessed patients and directed them to majors, resuscitation, Same Day Emergency Care (SDEC), or specialist units, supported by up‑to‑date and clinically appropriate standard operating procedures. The department also began improvements in the paediatric area, including the development of a new Child and Adolescent Mental Health Services (CAMHS) room and a “pop box” in the waiting area offering advice and reasonable adjustments for patients and families. However, we could not locate a LOOP system for hearing‑impaired patients, and signage was missing, which reduced accessibility.

We scored this quality statement 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.

Staff compliance with mandatory training was over 90% across most areas, above trust target compliance of 90%. Data shared some exceptions. For example, 9 nursing staff were uncertified in Basic Life Support (BLS). However, these staff members were on maternity leave or long‑term sick and could not be removed from the training data. A trust‑wide waiting list for Intermediate Life Support (ILS) training continued to affect compliance, with 47 nursing staff not certified. Leaders escalated this to the Resuscitation Training Team, who agreed to provide additional sessions. Demand for ILS training remained high across the organisation.

All medical staff completed BLS training during trust induction. Most Emergency Department (ED) doctors held Advanced Life Support (ALS) certification, which remained valid for four years. Compliance for medical staff appeared lower than it was in practice because delays occurred when new doctors’ existing ALS certificates were uploaded to the trust’s Training Information Management System. This resulted in artificially low training figures for this staff group.

Mandatory safeguarding training required improvement. Safeguarding Level 3 training compliance for ED) nursing staff was below the trust target of 90%, with compliance at 83%. A total of 20 nursing staff remained non‑compliant. The outstanding group included 10 registered nurses’ band 5 to 7, and 10 health care professionals (HCA’s) staff. The largest gaps were within Band 5 and HCA roles. Safeguarding Level 3 compliance for ED medical staff remained below the trust standard, with compliance at 82% and 12 medical staff still requiring completion.

Two Professional Development Nurses delivered training, supervision, and structured induction for new staff and students.

Mental health staffing provision within the Emergency Department (ED) was limited at the time of our inspection. Staff told us there were no mental health nurses available within the ED, and we did not meet any during our visit. As a result, staff felt the ED environment was not an appropriate setting for patients experiencing acute mental health needs and that the absence of specialist input increased risks for patients and the workforce, particularly when managing distressed or high‑risk individuals.

There was a substantive Mental Health Lead Nurse for adult and paediatric areas. Leaders told us that support was available from the external mental health team. They also explained that enhanced care, including Registered Mental Health Nursing support through the temporary workforce and trained healthcare support workers, could be put in place for patients requiring specialist mental health input. However, staff told us these arrangements were not consistently available within the ED, nor did we see it during our visit.

During the inspection, staff were caring for up to seven patients presenting with significant mental health concerns. To manage these pressures, the service relied on healthcare assistants with extended skills and occasional ad hoc booking of mental health nurses. While these mitigations provided short‑term support, staff raised concerns about their sustainability and the ongoing strain on the department without consistent specialist mental health input.

The absence of permanent mental health professionals in ED limited the team’s ability to provide timely assessments, therapeutic interventions, and appropriate de‑escalation for patients in crisis. This also placed additional pressure on ED nurses and doctors, who reported feeling they did not always have the specialist knowledge needed to manage complex mental health presentations safely.

Planned nurse staffing was mostly achieved, with day shifts averaging 98% and night shifts exceeding plan at 112%. Healthcare Assistant (HCA) cover exceeded planned numbers at night but were variable during the day, dropping to 91% in October. Leaders monitored fill rates and escalated shortfalls. Leaders made daily adjustments and agency use maintained safe levels, and temporary staff received induction.

Leaders used Safer Nursing Care Tool (SNCT) audits to identify staffing levels for corridor care. Using this tool, leaders identified 10 additional nurses to back-fill staffing from other wards. This extra resourcing was approved by the Executive Board. Corridor care was not intended to be a normal mode of operation and required leaders to redeploy staff to cover the unconventional environment.

Consultant cover was available from 08:00 to 22:00 daily, and leaders told us there were plans to extend this to midnight. Recruitment challenges had historically affected evening and weekend cover, but leaders reported that the consultant workforce had since expanded to 16 Whole Time Equivalents to support more consistent provision.

Middle‑tier medical staffing had improved and was in line with national guidance, with external oversight through regional tiering processes. Leaders explained that short‑term rota gaps, such as sickness, were escalated through the trust’s bed meetings held four times daily, and consultants made risk‑based decisions about staying beyond 22:00 when required to support safety.

We scored this quality statement as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Between January and November 2025, the IPC team led bi-monthly committee meetings to review audit data and compliance actions across paediatric and adult areas. The team examined 12 months of paediatric audits on hand hygiene and equipment cleaning. They identified persistent issues with equipment cleanliness and acted by replacing ineffective ‘I am Clean’ stickers with green tape, which improved visibility and compliance but did not fully meet standards. The team also shared updated hand hygiene policies, assigned responsible persons, and tracked progress using Red Amber and Green (RAG) ratings. RAG rating was a simple traffic light system used in trusts and other organisations to show risk, progress, performance or priority. Leaders shared audit data and compliance actions with paediatric and adult ED teams, resulting in steady improvement in hand hygiene compliance over the year.

In adult areas, the IPC team addressed ongoing concerns with commode cleanliness. They escalated the issue onto the risk register and implemented increased spot checks and regular monitoring in November 2025. Despite these actions, compliance remained below the expected standard, and the team continued to prioritise this risk. Across both areas, the IPC team developed action plans, communicated lessons learned, and monitored progress to drive improvement.

However, on assessment equipment was not always maintained or visibly clean; stickers were missing or out of date, creating uncertainty about safety checks. We observed dirty commodes, dusty equipment, and unclean floors in some areas, despite cleaning records being up to date. While compliance trends showed positive movement, achieving consistent adherence to IPC standards remained a key focus for improvement.

Monthly audits reported 100% hand hygiene compliance and 76% for commode cleaning. However, during our assessment, staff did not consistently follow infection control principles. Poor hand hygiene was observed between patient contact, and bare below elbow practice was not always maintained, with staff wearing long sleeves, jewellery and nail polish. This was reported to senior staff and by the second day of our assessment, jewellery and nail polish had been removed, and staff adhered to bare below the elbows.

These failures increased the risk of infection transmission between staff and patients.

Learning was shared through daily huddles, emails, and monthly nursing meetings, but recurring issues such as missing infection control details during handover suggested improvements were not fully embedded.

We scored this quality statement 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

During our visit we identified several medication‑related risks that required immediate escalation, and we raised these with staff at the time. In the resuscitation area, we observed a medication fridge that was unlocked and contained patient insulin, despite staff telling us it had been out of use due to being broken. The fridge was not marked as out of service, which created a risk that staff might inadvertently use it.

Staff informed us that a seizure‑control sedative had not been available in the area for a period of two days. Leaders later explained that this type of medication was not routinely stocked in the resuscitation area and would ordinarily be obtained from emergency drug storage if required or pre‑alerted.

We noted that some out‑of‑date medications were present, and concerns regarding the controlled drugs process were discussed with staff. These findings indicated the need for more robust medication‑checking processes, clearer communication, and stronger oversight to ensure timely identification and mitigation of risks.

Staff did not always handle medicines safely. Out of 8 medicines checked, 4 were out of date, including insulin and lidocaine. Checks on controlled drugs were not done according to national guidance and local policy; intravenous fluids were observed to be stored in unlocked drawers.

Staff did not complete the daily checks for the blood glucose and ketone machines. Records showed long gaps over several months, increasing the risk of inaccurate readings. Staff could not explain the missed checks.

Controlled drug checks observed during the inspection were not robust. Staff did not check expiry dates or visually inspect ampoules, which increased the risk of error.

Across quarter 1 to quarter 4 of 2025, medicine audits showed ongoing compliance issues. The Medicines Management team reviewed these results and created action plans. Staff identified gaps in medicine safety and storage, including not following the requirement for drug cupboard and fridge keys to be held by a registered nurse.

In response, the team strengthened communication about medicine safety. They shared messages through emails and safety huddles. Staff discussed audit findings during daily huddles, recorded discussions in governance meetings, and provided evidence through exception reports. The Medicines Optimisation Group monitored progress and fed back actions to support accountability.

In paediatric emergency care, staff demonstrated strong and consistent medicines management. All medicines reviewed were in date, stored securely, and daily checks were completed as required.